Public Act 097-0689
 
SB2840 EnrolledLRB097 15631 KTG 62714 b

    AN ACT concerning public aid.
 
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
 
    Section 1. Short title. This Act may be referred to as the
Save Medicaid Access and Resources Together (SMART) Act.
 
    Section 5. Purpose. In order to address the significant
spending and liability deficit in the medical assistance
program budget of the Department of Healthcare and Family
Services, the SMART Act hereby implements changes,
improvements, and efficiencies to enhance Medicaid program
integrity to prevent client and provider fraud; imposes
controls on use of Medicaid services to prevent over-use or
waste; expands cost-sharing by clients; redesigns the Medicaid
healthcare delivery system; and makes rate adjustments and
reductions to update rates or reflect budget realities.
 
    Section 10. The Illinois Administrative Procedure Act is
amended by changing Section 5-45 as follows:
 
    (5 ILCS 100/5-45)  (from Ch. 127, par. 1005-45)
    Sec. 5-45. Emergency rulemaking.
    (a) "Emergency" means the existence of any situation that
any agency finds reasonably constitutes a threat to the public
interest, safety, or welfare.
    (b) If any agency finds that an emergency exists that
requires adoption of a rule upon fewer days than is required by
Section 5-40 and states in writing its reasons for that
finding, the agency may adopt an emergency rule without prior
notice or hearing upon filing a notice of emergency rulemaking
with the Secretary of State under Section 5-70. The notice
shall include the text of the emergency rule and shall be
published in the Illinois Register. Consent orders or other
court orders adopting settlements negotiated by an agency may
be adopted under this Section. Subject to applicable
constitutional or statutory provisions, an emergency rule
becomes effective immediately upon filing under Section 5-65 or
at a stated date less than 10 days thereafter. The agency's
finding and a statement of the specific reasons for the finding
shall be filed with the rule. The agency shall take reasonable
and appropriate measures to make emergency rules known to the
persons who may be affected by them.
    (c) An emergency rule may be effective for a period of not
longer than 150 days, but the agency's authority to adopt an
identical rule under Section 5-40 is not precluded. No
emergency rule may be adopted more than once in any 24 month
period, except that this limitation on the number of emergency
rules that may be adopted in a 24 month period does not apply
to (i) emergency rules that make additions to and deletions
from the Drug Manual under Section 5-5.16 of the Illinois
Public Aid Code or the generic drug formulary under Section
3.14 of the Illinois Food, Drug and Cosmetic Act, (ii)
emergency rules adopted by the Pollution Control Board before
July 1, 1997 to implement portions of the Livestock Management
Facilities Act, (iii) emergency rules adopted by the Illinois
Department of Public Health under subsections (a) through (i)
of Section 2 of the Department of Public Health Act when
necessary to protect the public's health, (iv) emergency rules
adopted pursuant to subsection (n) of this Section, or (v)
emergency rules adopted pursuant to subsection (o) of this
Section. Two or more emergency rules having substantially the
same purpose and effect shall be deemed to be a single rule for
purposes of this Section.
    (d) In order to provide for the expeditious and timely
implementation of the State's fiscal year 1999 budget,
emergency rules to implement any provision of Public Act 90-587
or 90-588 or any other budget initiative for fiscal year 1999
may be adopted in accordance with this Section by the agency
charged with administering that provision or initiative,
except that the 24-month limitation on the adoption of
emergency rules and the provisions of Sections 5-115 and 5-125
do not apply to rules adopted under this subsection (d). The
adoption of emergency rules authorized by this subsection (d)
shall be deemed to be necessary for the public interest,
safety, and welfare.
    (e) In order to provide for the expeditious and timely
implementation of the State's fiscal year 2000 budget,
emergency rules to implement any provision of this amendatory
Act of the 91st General Assembly or any other budget initiative
for fiscal year 2000 may be adopted in accordance with this
Section by the agency charged with administering that provision
or initiative, except that the 24-month limitation on the
adoption of emergency rules and the provisions of Sections
5-115 and 5-125 do not apply to rules adopted under this
subsection (e). The adoption of emergency rules authorized by
this subsection (e) shall be deemed to be necessary for the
public interest, safety, and welfare.
    (f) In order to provide for the expeditious and timely
implementation of the State's fiscal year 2001 budget,
emergency rules to implement any provision of this amendatory
Act of the 91st General Assembly or any other budget initiative
for fiscal year 2001 may be adopted in accordance with this
Section by the agency charged with administering that provision
or initiative, except that the 24-month limitation on the
adoption of emergency rules and the provisions of Sections
5-115 and 5-125 do not apply to rules adopted under this
subsection (f). The adoption of emergency rules authorized by
this subsection (f) shall be deemed to be necessary for the
public interest, safety, and welfare.
    (g) In order to provide for the expeditious and timely
implementation of the State's fiscal year 2002 budget,
emergency rules to implement any provision of this amendatory
Act of the 92nd General Assembly or any other budget initiative
for fiscal year 2002 may be adopted in accordance with this
Section by the agency charged with administering that provision
or initiative, except that the 24-month limitation on the
adoption of emergency rules and the provisions of Sections
5-115 and 5-125 do not apply to rules adopted under this
subsection (g). The adoption of emergency rules authorized by
this subsection (g) shall be deemed to be necessary for the
public interest, safety, and welfare.
    (h) In order to provide for the expeditious and timely
implementation of the State's fiscal year 2003 budget,
emergency rules to implement any provision of this amendatory
Act of the 92nd General Assembly or any other budget initiative
for fiscal year 2003 may be adopted in accordance with this
Section by the agency charged with administering that provision
or initiative, except that the 24-month limitation on the
adoption of emergency rules and the provisions of Sections
5-115 and 5-125 do not apply to rules adopted under this
subsection (h). The adoption of emergency rules authorized by
this subsection (h) shall be deemed to be necessary for the
public interest, safety, and welfare.
    (i) In order to provide for the expeditious and timely
implementation of the State's fiscal year 2004 budget,
emergency rules to implement any provision of this amendatory
Act of the 93rd General Assembly or any other budget initiative
for fiscal year 2004 may be adopted in accordance with this
Section by the agency charged with administering that provision
or initiative, except that the 24-month limitation on the
adoption of emergency rules and the provisions of Sections
5-115 and 5-125 do not apply to rules adopted under this
subsection (i). The adoption of emergency rules authorized by
this subsection (i) shall be deemed to be necessary for the
public interest, safety, and welfare.
    (j) In order to provide for the expeditious and timely
implementation of the provisions of the State's fiscal year
2005 budget as provided under the Fiscal Year 2005 Budget
Implementation (Human Services) Act, emergency rules to
implement any provision of the Fiscal Year 2005 Budget
Implementation (Human Services) Act may be adopted in
accordance with this Section by the agency charged with
administering that provision, except that the 24-month
limitation on the adoption of emergency rules and the
provisions of Sections 5-115 and 5-125 do not apply to rules
adopted under this subsection (j). The Department of Public Aid
may also adopt rules under this subsection (j) necessary to
administer the Illinois Public Aid Code and the Children's
Health Insurance Program Act. The adoption of emergency rules
authorized by this subsection (j) shall be deemed to be
necessary for the public interest, safety, and welfare.
    (k) In order to provide for the expeditious and timely
implementation of the provisions of the State's fiscal year
2006 budget, emergency rules to implement any provision of this
amendatory Act of the 94th General Assembly or any other budget
initiative for fiscal year 2006 may be adopted in accordance
with this Section by the agency charged with administering that
provision or initiative, except that the 24-month limitation on
the adoption of emergency rules and the provisions of Sections
5-115 and 5-125 do not apply to rules adopted under this
subsection (k). The Department of Healthcare and Family
Services may also adopt rules under this subsection (k)
necessary to administer the Illinois Public Aid Code, the
Senior Citizens and Disabled Persons Property Tax Relief and
Pharmaceutical Assistance Act, the Senior Citizens and
Disabled Persons Prescription Drug Discount Program Act (now
the Illinois Prescription Drug Discount Program Act), and the
Children's Health Insurance Program Act. The adoption of
emergency rules authorized by this subsection (k) shall be
deemed to be necessary for the public interest, safety, and
welfare.
    (l) In order to provide for the expeditious and timely
implementation of the provisions of the State's fiscal year
2007 budget, the Department of Healthcare and Family Services
may adopt emergency rules during fiscal year 2007, including
rules effective July 1, 2007, in accordance with this
subsection to the extent necessary to administer the
Department's responsibilities with respect to amendments to
the State plans and Illinois waivers approved by the federal
Centers for Medicare and Medicaid Services necessitated by the
requirements of Title XIX and Title XXI of the federal Social
Security Act. The adoption of emergency rules authorized by
this subsection (l) shall be deemed to be necessary for the
public interest, safety, and welfare.
    (m) In order to provide for the expeditious and timely
implementation of the provisions of the State's fiscal year
2008 budget, the Department of Healthcare and Family Services
may adopt emergency rules during fiscal year 2008, including
rules effective July 1, 2008, in accordance with this
subsection to the extent necessary to administer the
Department's responsibilities with respect to amendments to
the State plans and Illinois waivers approved by the federal
Centers for Medicare and Medicaid Services necessitated by the
requirements of Title XIX and Title XXI of the federal Social
Security Act. The adoption of emergency rules authorized by
this subsection (m) shall be deemed to be necessary for the
public interest, safety, and welfare.
    (n) In order to provide for the expeditious and timely
implementation of the provisions of the State's fiscal year
2010 budget, emergency rules to implement any provision of this
amendatory Act of the 96th General Assembly or any other budget
initiative authorized by the 96th General Assembly for fiscal
year 2010 may be adopted in accordance with this Section by the
agency charged with administering that provision or
initiative. The adoption of emergency rules authorized by this
subsection (n) shall be deemed to be necessary for the public
interest, safety, and welfare. The rulemaking authority
granted in this subsection (n) shall apply only to rules
promulgated during Fiscal Year 2010.
    (o) In order to provide for the expeditious and timely
implementation of the provisions of the State's fiscal year
2011 budget, emergency rules to implement any provision of this
amendatory Act of the 96th General Assembly or any other budget
initiative authorized by the 96th General Assembly for fiscal
year 2011 may be adopted in accordance with this Section by the
agency charged with administering that provision or
initiative. The adoption of emergency rules authorized by this
subsection (o) is deemed to be necessary for the public
interest, safety, and welfare. The rulemaking authority
granted in this subsection (o) applies only to rules
promulgated on or after the effective date of this amendatory
Act of the 96th General Assembly through June 30, 2011.
    (p) In order to provide for the expeditious and timely
implementation of the provisions of this amendatory Act of the
97th General Assembly, emergency rules to implement any
provision of this amendatory Act of the 97th General Assembly
may be adopted in accordance with this subsection (p) by the
agency charged with administering that provision or
initiative. The 150-day limitation of the effective period of
emergency rules does not apply to rules adopted under this
subsection (p), and the effective period may continue through
June 30, 2013. The 24-month limitation on the adoption of
emergency rules does not apply to rules adopted under this
subsection (p). The adoption of emergency rules authorized by
this subsection (p) is deemed to be necessary for the public
interest, safety, and welfare.
(Source: P.A. 95-12, eff. 7-2-07; 95-331, eff. 8-21-07; 96-45,
eff. 7-15-09; 96-958, eff. 7-1-10; 96-1500, eff. 1-18-11.)
 
    Section 12. The Personnel Code is amended by changing
Section 4d as follows:
 
    (20 ILCS 415/4d)  (from Ch. 127, par. 63b104d)
    Sec. 4d. Partial exemptions. The following positions in
State service are exempt from jurisdictions A, B, and C to the
extent stated for each, unless those jurisdictions are extended
as provided in this Act:
        (1) In each department, board or commission that now
    maintains or may hereafter maintain a major administrative
    division, service or office in both Sangamon County and
    Cook County, 2 private secretaries for the director or
    chairman thereof, one located in the Cook County office and
    the other located in the Sangamon County office, shall be
    exempt from jurisdiction B; in all other departments,
    boards and commissions one private secretary for the
    director or chairman thereof shall be exempt from
    jurisdiction B. In all departments, boards and commissions
    one confidential assistant for the director or chairman
    thereof shall be exempt from jurisdiction B. This paragraph
    is subject to such modifications or waiver of the
    exemptions as may be necessary to assure the continuity of
    federal contributions in those agencies supported in whole
    or in part by federal funds.
        (2) The resident administrative head of each State
    charitable, penal and correctional institution, the
    chaplains thereof, and all member, patient and inmate
    employees are exempt from jurisdiction B.
        (3) The Civil Service Commission, upon written
    recommendation of the Director of Central Management
    Services, shall exempt from jurisdiction B other positions
    which, in the judgment of the Commission, involve either
    principal administrative responsibility for the
    determination of policy or principal administrative
    responsibility for the way in which policies are carried
    out, except positions in agencies which receive federal
    funds if such exemption is inconsistent with federal
    requirements, and except positions in agencies supported
    in whole by federal funds.
        (4) All beauticians and teachers of beauty culture and
    teachers of barbering, and all positions heretofore paid
    under Section 1.22 of "An Act to standardize position
    titles and salary rates", approved June 30, 1943, as
    amended, shall be exempt from jurisdiction B.
        (5) Licensed attorneys in positions as legal or
    technical advisors, positions in the Department of Natural
    Resources requiring incumbents to be either a registered
    professional engineer or to hold a bachelor's degree in
    engineering from a recognized college or university,
    licensed physicians in positions of medical administrator
    or physician or physician specialist (including
    psychiatrists), and registered nurses (except those
    registered nurses employed by the Department of Public
    Health), except those in positions in agencies which
    receive federal funds if such exemption is inconsistent
    with federal requirements and except those in positions in
    agencies supported in whole by federal funds, are exempt
    from jurisdiction B only to the extent that the
    requirements of Section 8b.1, 8b.3 and 8b.5 of this Code
    need not be met.
        (6) All positions established outside the geographical
    limits of the State of Illinois to which appointments of
    other than Illinois citizens may be made are exempt from
    jurisdiction B.
        (7) Staff attorneys reporting directly to individual
    Commissioners of the Illinois Workers' Compensation
    Commission are exempt from jurisdiction B.
        (8) Twenty-one Twenty senior public service
    administrator positions within the Department of
    Healthcare and Family Services, as set forth in this
    paragraph (8), requiring the specific knowledge of
    healthcare administration, healthcare finance, healthcare
    data analytics, or information technology described are
    exempt from jurisdiction B only to the extent that the
    requirements of Sections 8b.1, 8b.3, and 8b.5 of this Code
    need not be met. The General Assembly finds that these
    positions are all senior policy makers and have
    spokesperson authority for the Director of the Department
    of Healthcare and Family Services. When filling positions
    so designated, the Director of Healthcare and Family
    Services shall cause a position description to be published
    which allots points to various qualifications desired.
    After scoring qualified applications, the Director shall
    add Veteran's Preference points as enumerated in Section
    8b.7 of this Code. The following are the minimum
    qualifications for the senior public service administrator
    positions provided for in this paragraph (8):
            (A) HEALTHCARE ADMINISTRATION.
                Medical Director: Licensed Medical Doctor in
            good standing; experience in healthcare payment
            systems, pay for performance initiatives, medical
            necessity criteria or federal or State quality
            improvement programs; preferred experience serving
            Medicaid patients or experience in population
            health programs with a large provider, health
            insurer, government agency, or research
            institution.
                Chief, Bureau of Quality Management: Advanced
            degree in health policy or health professional
            field preferred; at least 3 years experience in
            implementing or managing healthcare quality
            improvement initiatives in a clinical setting.
                Quality Management Bureau: Manager, Care
            Coordination/Managed Care Quality: Clinical degree
            or advanced degree in relevant field required;
            experience in the field of managed care quality
            improvement, with knowledge of HEDIS measurements,
            coding, and related data definitions.
                Quality Management Bureau: Manager, Primary
            Care Provider Quality and Practice Development:
            Clinical degree or advanced degree in relevant
            field required; experience in practice
            administration in the primary care setting with a
            provider or a provider association or an
            accrediting body; knowledge of practice standards
            for medical homes and best evidence based
            standards of care for primary care.
                Director of Care Coordination Contracts and
            Compliance: Bachelor's degree required; multi-year
            experience in negotiating managed care contracts,
            preferably on behalf of a payer; experience with
            health care contract compliance.
                Manager, Long Term Care Policy: Bachelor's
            degree required; social work, gerontology, or
            social service degree preferred; knowledge of
            Olmstead and other relevant court decisions
            required; experience working with diverse long
            term care populations and service systems, federal
            initiatives to create long term care community
            options, and home and community-based waiver
            services required. The General Assembly finds that
            this position is necessary for the timely and
            effective implementation of this amendatory Act of
            the 97th General Assembly.
                Manager, Behavioral Health Programs: Clinical
            license or Advanced degree required, preferably in
            psychology, social work, or relevant field;
            knowledge of medical necessity criteria and
            governmental policies and regulations governing
            the provision of mental health services to
            Medicaid populations, including children and
            adults, in community and institutional settings of
            care. The General Assembly finds that this
            position is necessary for the timely and effective
            implementation of this amendatory Act of the 97th
            General Assembly.
                Chief, Bureau of Pharmacy Services: Bachelor's
            degree required; pharmacy degree preferred; in
            formulary development and management from both a
            clinical and financial perspective, experience in
            prescription drug utilization review and
            utilization control policies, knowledge of retail
            pharmacy reimbursement policies and methodologies
            and available benchmarks, knowledge of Medicare
            Part D benefit design.
                Chief, Bureau of Maternal and Child Health
            Promotion: Bachelor's degree required, advanced
            degree preferred, in public health, health care
            management, or a clinical field; multi-year
            experience in health care or public health
            management; knowledge of federal EPSDT
            requirements and strategies for improving health
            care for children as well as improving birth
            outcomes.
                Director of Dental Program: Bachelor's degree
            required, advanced degree preferred, in healthcare
            management or relevant field; experience in
            healthcare administration; experience in
            administering dental healthcare programs,
            knowledge of practice standards for dental care
            and treatment services; knowledge of the public
            dental health infrastructure.
                Manager of Medicare/Medicaid Coordination:
            Bachelor's degree required, knowledge and
            experience with Medicare Advantage rules and
            regulations, knowledge of Medicaid laws and
            policies; experience with contract drafting
            preferred.
                Chief, Bureau of Eligibility Integrity:
            Bachelor's degree required, advanced degree in
            public administration or business administration
            preferred; experience equivalent to 4 years of
            administration in a public or business
            organization required; experience with managing
            contract compliance required; knowledge of
            Medicaid eligibility laws and policy preferred;
            supervisory experience preferred. The General
            Assembly finds that this position is necessary for
            the timely and effective implementation of this
            amendatory Act of the 97th General Assembly.
            (B) HEALTHCARE FINANCE.
                Director of Care Coordination Rate and
            Finance: MBA, CPA, or Actuarial degree required;
            experience in managed care rate setting,
            including, but not limited to, baseline costs and
            growth trends; knowledge and experience with
            Medical Loss Ratio standards and measurements.
                Director of Encounter Data Program: Bachelor's
            degree required, advanced degree preferred,
            preferably in business or information systems; at
            least 2 years healthcare data reporting
            experience, including, but not limited to, data
            definitions, submission, and editing; strong
            background in HIPAA transactions relevant to
            encounter data submission; knowledge of healthcare
            claims systems.
                Chief, Bureau of Rate Development and
            Analysis: Bachelor's degree required, advanced
            degree preferred, with preferred coursework in
            business or public administration, accounting,
            finance, data analysis, or statistics; experience
            with Medicaid reimbursement methodologies and
            regulations; experience with extracting data from
            large systems for analysis.
                Manager of Medical Finance, Division of
            Finance: Requires relevant advanced degree or
            certification in relevant field, such as Certified
            Public Accountant; coursework in business or
            public administration, accounting, finance, data
            analysis, or statistics preferred; experience in
            control systems and GAAP; financial management
            experience in a healthcare or government entity
            utilizing Medicaid funding.
            (C) HEALTHCARE DATA ANALYTICS.
                Data Quality Assurance Manager: Bachelor's
            degree required, advanced degree preferred,
            preferably in business, information systems, or
            epidemiology; at least 3 years of extensive
            healthcare data reporting experience with a large
            provider, health insurer, government agency, or
            research institution; previous data quality
            assurance role or formal data quality assurance
            training.
                Data Analytics Unit Manager: Bachelor's degree
            required, advanced degree preferred, in
            information systems, applied mathematics, or
            another field with a strong analytics component;
            extensive healthcare data reporting experience
            with a large provider, health insurer, government
            agency, or research institution; experience as a
            business analyst interfacing between business and
            information technology departments; in-depth
            knowledge of health insurance coding and evolving
            healthcare quality metrics; working knowledge of
            SQL and/or SAS.
                Data Analytics Platform Manager: Bachelor's
            degree required, advanced degree preferred,
            preferably in business or information systems;
            extensive healthcare data reporting experience
            with a large provider, health insurer, government
            agency, or research institution; previous
            experience working on a health insurance data
            analytics platform; experience managing contracts
            and vendors preferred.
            (D) HEALTHCARE INFORMATION TECHNOLOGY.
                Manager of Recipient Provider Reference Unit:
            Bachelor's degree required; experience equivalent
            to 4 years of administration in a public or
            business organization; 3 years of administrative
            experience in a computer-based management
            information system.
                Manager of MMIS Claims Unit: Bachelor's degree
            required, with preferred coursework in business,
            public administration, information systems;
            experience equivalent to 4 years of administration
            in a public or business organization; working
            knowledge with design and implementation of
            technical solutions to medical claims payment
            systems; extensive technical writing experience,
            including, but not limited to, the development of
            RFPs, APDs, feasibility studies, and related
            documents; thorough knowledge of IT system design,
            commercial off the shelf software packages and
            hardware components.
                Assistant Bureau Chief, Office of Information
            Systems: Bachelor's degree required, with
            preferred coursework in business, public
            administration, information systems; experience
            equivalent to 5 years of administration in a public
            or private business organization; extensive
            technical writing experience, including, but not
            limited to, the development of RFPs, APDs,
            feasibility studies and related documents;
            extensive healthcare technology experience with a
            large provider, health insurer, government agency,
            or research institution; experience as a business
            analyst interfacing between business and
            information technology departments; thorough
            knowledge of IT system design, commercial off the
            shelf software packages and hardware components.
                Technical System Architect: Bachelor's degree
            required, with preferred coursework in computer
            science or information technology; prior
            experience equivalent to 5 years of computer
            science or IT administration in a public or
            business organization; extensive healthcare
            technology experience with a large provider,
            health insurer, government agency, or research
            institution; experience as a business analyst
            interfacing between business and information
            technology departments.
    The provisions of this paragraph (8), other than this
    sentence, are inoperative after January 1, 2014.
(Source: P.A. 97-649, eff. 12-30-11.)
 
    Section 14. The Illinois State Auditing Act is amended by
adding Section 2-20 as follows:
 
    (30 ILCS 5/2-20 new)
    Sec. 2-20. Certification of federal waivers and amendments
to the Illinois Title XIX State plan.
    (a) No later than August 1, 2012, the Department shall file
a report with the Auditor General, the Governor, the Speaker of
the House of Representatives, the Minority Leader of the House
of Representatives, the Senate President, and the Senate
Minority Leader listing any necessary amendment to the Illinois
Title XIX State plan, federal waiver request, or State
administrative rule required to implement this amendatory Act
of the 97th General Assembly.
    (b) No later than March 1, 2013, the Department shall
provide evidence to the Auditor General that it has undertaken
the required actions listed in the report required by
subsection (a).
    (c) No later than May 1, 2013, the Auditor General shall
submit a report to the Governor, the Speaker of the House of
Representatives, the Minority Leader of the House of
Representatives, the Senate President, and the Senate Minority
Leader as to whether the Department has undertaken the required
actions listed in the report required by subsection (a).
 
    Section 15. The State Finance Act is amended by changing
Sections 6z-52 and 13.2 as follows:
 
    (30 ILCS 105/6z-52)
    Sec. 6z-52. Drug Rebate Fund.
    (a) There is created in the State Treasury a special fund
to be known as the Drug Rebate Fund.
    (b) The Fund is created for the purpose of receiving and
disbursing moneys in accordance with this Section.
Disbursements from the Fund shall be made, subject to
appropriation, only as follows:
        (1) For payments for reimbursement or coverage for
    prescription drugs and other pharmacy products provided to
    a recipient of medical assistance under the Illinois Public
    Aid Code, the Children's Health Insurance Program Act, the
    Covering ALL KIDS Health Insurance Act, and the Veterans'
    Health Insurance Program Act of 2008, and the Senior
    Citizens and Disabled Persons Property Tax Relief and
    Pharmaceutical Assistance Act.
        (2) For reimbursement of moneys collected by the
    Department of Healthcare and Family Services (formerly
    Illinois Department of Public Aid) through error or
    mistake.
        (3) For payments of any amounts that are reimbursable
    to the federal government resulting from a payment into
    this Fund.
        (4) For payments of operational and administrative
    expenses related to providing and managing coverage for
    prescription drugs and other pharmacy products provided to
    a recipient of medical assistance under the Illinois Public
    Aid Code, the Children's Health Insurance Program Act, the
    Covering ALL KIDS Health Insurance Act, the Veterans'
    Health Insurance Program Act of 2008, and the Senior
    Citizens and Disabled Persons Property Tax Relief and
    Pharmaceutical Assistance Act.
    (c) The Fund shall consist of the following:
        (1) Upon notification from the Director of Healthcare
    and Family Services, the Comptroller shall direct and the
    Treasurer shall transfer the net State share (disregarding
    the reduction in net State share attributable to the
    American Recovery and Reinvestment Act of 2009 or any other
    federal economic stimulus program) of all moneys received
    by the Department of Healthcare and Family Services
    (formerly Illinois Department of Public Aid) from drug
    rebate agreements with pharmaceutical manufacturers
    pursuant to Title XIX of the federal Social Security Act,
    including any portion of the balance in the Public Aid
    Recoveries Trust Fund on July 1, 2001 that is attributable
    to such receipts.
        (2) All federal matching funds received by the Illinois
    Department as a result of expenditures made by the
    Department that are attributable to moneys deposited in the
    Fund.
        (3) Any premium collected by the Illinois Department
    from participants under a waiver approved by the federal
    government relating to provision of pharmaceutical
    services.
        (4) All other moneys received for the Fund from any
    other source, including interest earned thereon.
(Source: P.A. 95-331, eff. 8-21-07; 96-8, eff. 4-28-09;
96-1100, eff. 1-1-11.)
 
    (30 ILCS 105/13.2)  (from Ch. 127, par. 149.2)
    Sec. 13.2. Transfers among line item appropriations.
    (a) Transfers among line item appropriations from the same
treasury fund for the objects specified in this Section may be
made in the manner provided in this Section when the balance
remaining in one or more such line item appropriations is
insufficient for the purpose for which the appropriation was
made.
    (a-1) No transfers may be made from one agency to another
agency, nor may transfers be made from one institution of
higher education to another institution of higher education
except as provided by subsection (a-4).
    (a-2) Except as otherwise provided in this Section,
transfers may be made only among the objects of expenditure
enumerated in this Section, except that no funds may be
transferred from any appropriation for personal services, from
any appropriation for State contributions to the State
Employees' Retirement System, from any separate appropriation
for employee retirement contributions paid by the employer, nor
from any appropriation for State contribution for employee
group insurance. During State fiscal year 2005, an agency may
transfer amounts among its appropriations within the same
treasury fund for personal services, employee retirement
contributions paid by employer, and State Contributions to
retirement systems; notwithstanding and in addition to the
transfers authorized in subsection (c) of this Section, the
fiscal year 2005 transfers authorized in this sentence may be
made in an amount not to exceed 2% of the aggregate amount
appropriated to an agency within the same treasury fund. During
State fiscal year 2007, the Departments of Children and Family
Services, Corrections, Human Services, and Juvenile Justice
may transfer amounts among their respective appropriations
within the same treasury fund for personal services, employee
retirement contributions paid by employer, and State
contributions to retirement systems. During State fiscal year
2010, the Department of Transportation may transfer amounts
among their respective appropriations within the same treasury
fund for personal services, employee retirement contributions
paid by employer, and State contributions to retirement
systems. During State fiscal year 2010 only, an agency may
transfer amounts among its respective appropriations within
the same treasury fund for personal services, employee
retirement contributions paid by employer, and State
contributions to retirement systems. Notwithstanding, and in
addition to, the transfers authorized in subsection (c) of this
Section, these transfers may be made in an amount not to exceed
2% of the aggregate amount appropriated to an agency within the
same treasury fund.
    (a-3) Further, if an agency receives a separate
appropriation for employee retirement contributions paid by
the employer, any transfer by that agency into an appropriation
for personal services must be accompanied by a corresponding
transfer into the appropriation for employee retirement
contributions paid by the employer, in an amount sufficient to
meet the employer share of the employee contributions required
to be remitted to the retirement system.
    (a-4) Long-Term Care Rebalancing. The Governor may
designate amounts set aside for institutional services
appropriated from the General Revenue Fund or any other State
fund that receives monies for long-term care services to be
transferred to all State agencies responsible for the
administration of community-based long-term care programs,
including, but not limited to, community-based long-term care
programs administered by the Department of Healthcare and
Family Services, the Department of Human Services, and the
Department on Aging, provided that the Director of Healthcare
and Family Services first certifies that the amounts being
transferred are necessary for the purpose of assisting persons
in or at risk of being in institutional care to transition to
community-based settings, including the financial data needed
to prove the need for the transfer of funds. The total amounts
transferred shall not exceed 4% in total of the amounts
appropriated from the General Revenue Fund or any other State
fund that receives monies for long-term care services for each
fiscal year. A notice of the fund transfer must be made to the
General Assembly and posted at a minimum on the Department of
Healthcare and Family Services website, the Governor's Office
of Management and Budget website, and any other website the
Governor sees fit. These postings shall serve as notice to the
General Assembly of the amounts to be transferred. Notice shall
be given at least 30 days prior to transfer.
    (b) In addition to the general transfer authority provided
under subsection (c), the following agencies have the specific
transfer authority granted in this subsection:
    The Department of Healthcare and Family Services is
authorized to make transfers representing savings attributable
to not increasing grants due to the births of additional
children from line items for payments of cash grants to line
items for payments for employment and social services for the
purposes outlined in subsection (f) of Section 4-2 of the
Illinois Public Aid Code.
    The Department of Children and Family Services is
authorized to make transfers not exceeding 2% of the aggregate
amount appropriated to it within the same treasury fund for the
following line items among these same line items: Foster Home
and Specialized Foster Care and Prevention, Institutions and
Group Homes and Prevention, and Purchase of Adoption and
Guardianship Services.
    The Department on Aging is authorized to make transfers not
exceeding 2% of the aggregate amount appropriated to it within
the same treasury fund for the following Community Care Program
line items among these same line items: Homemaker and Senior
Companion Services, Alternative Senior Services, Case
Coordination Units, and Adult Day Care Services.
    The State Treasurer is authorized to make transfers among
line item appropriations from the Capital Litigation Trust
Fund, with respect to costs incurred in fiscal years 2002 and
2003 only, when the balance remaining in one or more such line
item appropriations is insufficient for the purpose for which
the appropriation was made, provided that no such transfer may
be made unless the amount transferred is no longer required for
the purpose for which that appropriation was made.
    The State Board of Education is authorized to make
transfers from line item appropriations within the same
treasury fund for General State Aid and General State Aid -
Hold Harmless, provided that no such transfer may be made
unless the amount transferred is no longer required for the
purpose for which that appropriation was made, to the line item
appropriation for Transitional Assistance when the balance
remaining in such line item appropriation is insufficient for
the purpose for which the appropriation was made.
    The State Board of Education is authorized to make
transfers between the following line item appropriations
within the same treasury fund: Disabled Student
Services/Materials (Section 14-13.01 of the School Code),
Disabled Student Transportation Reimbursement (Section
14-13.01 of the School Code), Disabled Student Tuition -
Private Tuition (Section 14-7.02 of the School Code),
Extraordinary Special Education (Section 14-7.02b of the
School Code), Reimbursement for Free Lunch/Breakfast Program,
Summer School Payments (Section 18-4.3 of the School Code), and
Transportation - Regular/Vocational Reimbursement (Section
29-5 of the School Code). Such transfers shall be made only
when the balance remaining in one or more such line item
appropriations is insufficient for the purpose for which the
appropriation was made and provided that no such transfer may
be made unless the amount transferred is no longer required for
the purpose for which that appropriation was made.
    The During State fiscal years 2010 and 2011 only, the
Department of Healthcare and Family Services is authorized to
make transfers not exceeding 4% of the aggregate amount
appropriated to it, within the same treasury fund, among the
various line items appropriated for Medical Assistance.
    (c) The sum of such transfers for an agency in a fiscal
year shall not exceed 2% of the aggregate amount appropriated
to it within the same treasury fund for the following objects:
Personal Services; Extra Help; Student and Inmate
Compensation; State Contributions to Retirement Systems; State
Contributions to Social Security; State Contribution for
Employee Group Insurance; Contractual Services; Travel;
Commodities; Printing; Equipment; Electronic Data Processing;
Operation of Automotive Equipment; Telecommunications
Services; Travel and Allowance for Committed, Paroled and
Discharged Prisoners; Library Books; Federal Matching Grants
for Student Loans; Refunds; Workers' Compensation,
Occupational Disease, and Tort Claims; and, in appropriations
to institutions of higher education, Awards and Grants.
Notwithstanding the above, any amounts appropriated for
payment of workers' compensation claims to an agency to which
the authority to evaluate, administer and pay such claims has
been delegated by the Department of Central Management Services
may be transferred to any other expenditure object where such
amounts exceed the amount necessary for the payment of such
claims.
    (c-1) Special provisions for State fiscal year 2003.
Notwithstanding any other provision of this Section to the
contrary, for State fiscal year 2003 only, transfers among line
item appropriations to an agency from the same treasury fund
may be made provided that the sum of such transfers for an
agency in State fiscal year 2003 shall not exceed 3% of the
aggregate amount appropriated to that State agency for State
fiscal year 2003 for the following objects: personal services,
except that no transfer may be approved which reduces the
aggregate appropriations for personal services within an
agency; extra help; student and inmate compensation; State
contributions to retirement systems; State contributions to
social security; State contributions for employee group
insurance; contractual services; travel; commodities;
printing; equipment; electronic data processing; operation of
automotive equipment; telecommunications services; travel and
allowance for committed, paroled, and discharged prisoners;
library books; federal matching grants for student loans;
refunds; workers' compensation, occupational disease, and tort
claims; and, in appropriations to institutions of higher
education, awards and grants.
    (c-2) Special provisions for State fiscal year 2005.
Notwithstanding subsections (a), (a-2), and (c), for State
fiscal year 2005 only, transfers may be made among any line
item appropriations from the same or any other treasury fund
for any objects or purposes, without limitation, when the
balance remaining in one or more such line item appropriations
is insufficient for the purpose for which the appropriation was
made, provided that the sum of those transfers by a State
agency shall not exceed 4% of the aggregate amount appropriated
to that State agency for fiscal year 2005.
    (d) Transfers among appropriations made to agencies of the
Legislative and Judicial departments and to the
constitutionally elected officers in the Executive branch
require the approval of the officer authorized in Section 10 of
this Act to approve and certify vouchers. Transfers among
appropriations made to the University of Illinois, Southern
Illinois University, Chicago State University, Eastern
Illinois University, Governors State University, Illinois
State University, Northeastern Illinois University, Northern
Illinois University, Western Illinois University, the Illinois
Mathematics and Science Academy and the Board of Higher
Education require the approval of the Board of Higher Education
and the Governor. Transfers among appropriations to all other
agencies require the approval of the Governor.
    The officer responsible for approval shall certify that the
transfer is necessary to carry out the programs and purposes
for which the appropriations were made by the General Assembly
and shall transmit to the State Comptroller a certified copy of
the approval which shall set forth the specific amounts
transferred so that the Comptroller may change his records
accordingly. The Comptroller shall furnish the Governor with
information copies of all transfers approved for agencies of
the Legislative and Judicial departments and transfers
approved by the constitutionally elected officials of the
Executive branch other than the Governor, showing the amounts
transferred and indicating the dates such changes were entered
on the Comptroller's records.
    (e) The State Board of Education, in consultation with the
State Comptroller, may transfer line item appropriations for
General State Aid between the Common School Fund and the
Education Assistance Fund. With the advice and consent of the
Governor's Office of Management and Budget, the State Board of
Education, in consultation with the State Comptroller, may
transfer line item appropriations between the General Revenue
Fund and the Education Assistance Fund for the following
programs:
        (1) Disabled Student Personnel Reimbursement (Section
    14-13.01 of the School Code);
        (2) Disabled Student Transportation Reimbursement
    (subsection (b) of Section 14-13.01 of the School Code);
        (3) Disabled Student Tuition - Private Tuition
    (Section 14-7.02 of the School Code);
        (4) Extraordinary Special Education (Section 14-7.02b
    of the School Code);
        (5) Reimbursement for Free Lunch/Breakfast Programs;
        (6) Summer School Payments (Section 18-4.3 of the
    School Code);
        (7) Transportation - Regular/Vocational Reimbursement
    (Section 29-5 of the School Code);
        (8) Regular Education Reimbursement (Section 18-3 of
    the School Code); and
        (9) Special Education Reimbursement (Section 14-7.03
    of the School Code).
(Source: P.A. 95-707, eff. 1-11-08; 96-37, eff. 7-13-09;
96-820, eff. 11-18-09; 96-959, eff. 7-1-10; 96-1086, eff.
7-16-10; 96-1501, eff. 1-25-11.)
 
    (30 ILCS 105/5.441 rep.)
    (30 ILCS 105/5.442 rep.)
    (30 ILCS 105/5.549 rep.)
    Section 20. The State Finance Act is amended by repealing
Sections 5.441, 5.442, and 5.549.
 
    Section 25. The Illinois Procurement Code is amended by
changing Section 1-10 as follows:
 
    (30 ILCS 500/1-10)
    Sec. 1-10. Application.
    (a) This Code applies only to procurements for which
contractors were first solicited on or after July 1, 1998. This
Code shall not be construed to affect or impair any contract,
or any provision of a contract, entered into based on a
solicitation prior to the implementation date of this Code as
described in Article 99, including but not limited to any
covenant entered into with respect to any revenue bonds or
similar instruments. All procurements for which contracts are
solicited between the effective date of Articles 50 and 99 and
July 1, 1998 shall be substantially in accordance with this
Code and its intent.
    (b) This Code shall apply regardless of the source of the
funds with which the contracts are paid, including federal
assistance moneys. This Code shall not apply to:
        (1) Contracts between the State and its political
    subdivisions or other governments, or between State
    governmental bodies except as specifically provided in
    this Code.
        (2) Grants, except for the filing requirements of
    Section 20-80.
        (3) Purchase of care.
        (4) Hiring of an individual as employee and not as an
    independent contractor, whether pursuant to an employment
    code or policy or by contract directly with that
    individual.
        (5) Collective bargaining contracts.
        (6) Purchase of real estate, except that notice of this
    type of contract with a value of more than $25,000 must be
    published in the Procurement Bulletin within 7 days after
    the deed is recorded in the county of jurisdiction. The
    notice shall identify the real estate purchased, the names
    of all parties to the contract, the value of the contract,
    and the effective date of the contract.
        (7) Contracts necessary to prepare for anticipated
    litigation, enforcement actions, or investigations,
    provided that the chief legal counsel to the Governor shall
    give his or her prior approval when the procuring agency is
    one subject to the jurisdiction of the Governor, and
    provided that the chief legal counsel of any other
    procuring entity subject to this Code shall give his or her
    prior approval when the procuring entity is not one subject
    to the jurisdiction of the Governor.
        (8) Contracts for services to Northern Illinois
    University by a person, acting as an independent
    contractor, who is qualified by education, experience, and
    technical ability and is selected by negotiation for the
    purpose of providing non-credit educational service
    activities or products by means of specialized programs
    offered by the university.
        (9) Procurement expenditures by the Illinois
    Conservation Foundation when only private funds are used.
        (10) Procurement expenditures by the Illinois Health
    Information Exchange Authority involving private funds
    from the Health Information Exchange Fund. "Private funds"
    means gifts, donations, and private grants.
        (11) Public-private agreements entered into according
    to the procurement requirements of Section 20 of the
    Public-Private Partnerships for Transportation Act and
    design-build agreements entered into according to the
    procurement requirements of Section 25 of the
    Public-Private Partnerships for Transportation Act.
    (c) This Code does not apply to the electric power
procurement process provided for under Section 1-75 of the
Illinois Power Agency Act and Section 16-111.5 of the Public
Utilities Act.
    (d) Except for Section 20-160 and Article 50 of this Code,
and as expressly required by Section 9.1 of the Illinois
Lottery Law, the provisions of this Code do not apply to the
procurement process provided for under Section 9.1 of the
Illinois Lottery Law.
    (e) This Code does not apply to the process used by the
Capital Development Board to retain a person or entity to
assist the Capital Development Board with its duties related to
the determination of costs of a clean coal SNG brownfield
facility, as defined by Section 1-10 of the Illinois Power
Agency Act, as required in subsection (h-3) of Section 9-220 of
the Public Utilities Act, including calculating the range of
capital costs, the range of operating and maintenance costs, or
the sequestration costs or monitoring the construction of clean
coal SNG brownfield facility for the full duration of
construction.
    (f) This Code does not apply to the process used by the
Illinois Power Agency to retain a mediator to mediate sourcing
agreement disputes between gas utilities and the clean coal SNG
brownfield facility, as defined in Section 1-10 of the Illinois
Power Agency Act, as required under subsection (h-1) of Section
9-220 of the Public Utilities Act.
    (g) (e) This Code does not apply to the processes used by
the Illinois Power Agency to retain a mediator to mediate
contract disputes between gas utilities and the clean coal SNG
facility and to retain an expert to assist in the review of
contracts under subsection (h) of Section 9-220 of the Public
Utilities Act. This Code does not apply to the process used by
the Illinois Commerce Commission to retain an expert to assist
in determining the actual incurred costs of the clean coal SNG
facility and the reasonableness of those costs as required
under subsection (h) of Section 9-220 of the Public Utilities
Act.
    (h) This Code does not apply to the process to procure or
contracts entered into in accordance with Sections 11-5.2 and
11-5.3 of the Illinois Public Aid Code.
(Source: P.A. 96-840, eff. 12-23-09; 96-1331, eff. 7-27-10;
97-96, eff. 7-13-11; 97-239, eff. 8-2-11; 97-502, eff. 8-23-11;
revised 9-7-11.)
 
    (30 ILCS 775/Act rep.)
    Section 30. The Excellence in Academic Medicine Act is
repealed.
 
    Section 45. The Nursing Home Care Act is amended by
changing Section 3-202.05 as follows:
 
    (210 ILCS 45/3-202.05)
    Sec. 3-202.05. Staffing ratios effective July 1, 2010 and
thereafter.
    (a) For the purpose of computing staff to resident ratios,
direct care staff shall include:
        (1) registered nurses;
        (2) licensed practical nurses;
        (3) certified nurse assistants;
        (4) psychiatric services rehabilitation aides;
        (5) rehabilitation and therapy aides;
        (6) psychiatric services rehabilitation coordinators;
        (7) assistant directors of nursing;
        (8) 50% of the Director of Nurses' time; and
        (9) 30% of the Social Services Directors' time.
    The Department shall, by rule, allow certain facilities
subject to 77 Ill. Admin. Code 300.4000 and following (Subpart
S) and 300.6000 and following (Subpart T) to utilize
specialized clinical staff, as defined in rules, to count
towards the staffing ratios.
    Within 120 days of the effective date of this amendatory
Act of the 97th General Assembly, the Department shall
promulgate rules specific to the staffing requirements for
facilities federally defined as Institutions for Mental
Disease. These rules shall recognize the unique nature of
individuals with chronic mental health conditions, shall
include minimum requirements for specialized clinical staff,
including clinical social workers, psychiatrists,
psychologists, and direct care staff set forth in paragraphs
(4) through (6) and any other specialized staff which may be
utilized and deemed necessary to count toward staffing ratios.
    Within 120 days of the effective date of this amendatory
Act of the 97th General Assembly, the Department shall
promulgate rules specific to the staffing requirements for
facilities licensed under the Specialized Mental Health
Rehabilitation Act. These rules shall recognize the unique
nature of individuals with chronic mental health conditions,
shall include minimum requirements for specialized clinical
staff, including clinical social workers, psychiatrists,
psychologists, and direct care staff set forth in paragraphs
(4) through (6) and any other specialized staff which may be
utilized and deemed necessary to count toward staffing ratios.
    (b) Beginning January 1, 2011, and thereafter, light
intermediate care shall be staffed at the same staffing ratio
as intermediate care.
    (c) Facilities shall notify the Department within 60 days
after the effective date of this amendatory Act of the 96th
General Assembly, in a form and manner prescribed by the
Department, of the staffing ratios in effect on the effective
date of this amendatory Act of the 96th General Assembly for
both intermediate and skilled care and the number of residents
receiving each level of care.
    (d)(1) Effective July 1, 2010, for each resident needing
skilled care, a minimum staffing ratio of 2.5 hours of nursing
and personal care each day must be provided; for each resident
needing intermediate care, 1.7 hours of nursing and personal
care each day must be provided.
    (2) Effective January 1, 2011, the minimum staffing ratios
shall be increased to 2.7 hours of nursing and personal care
each day for a resident needing skilled care and 1.9 hours of
nursing and personal care each day for a resident needing
intermediate care.
    (3) Effective January 1, 2012, the minimum staffing ratios
shall be increased to 3.0 hours of nursing and personal care
each day for a resident needing skilled care and 2.1 hours of
nursing and personal care each day for a resident needing
intermediate care.
    (4) Effective January 1, 2013, the minimum staffing ratios
shall be increased to 3.4 hours of nursing and personal care
each day for a resident needing skilled care and 2.3 hours of
nursing and personal care each day for a resident needing
intermediate care.
    (5) Effective January 1, 2014, the minimum staffing ratios
shall be increased to 3.8 hours of nursing and personal care
each day for a resident needing skilled care and 2.5 hours of
nursing and personal care each day for a resident needing
intermediate care.
    (e) Ninety days after the effective date of this amendatory
Act of the 97th General Assembly, a minimum of 25% of nursing
and personal care time shall be provided by licensed nurses,
with at least 10% of nursing and personal care time provided by
registered nurses. These minimum requirements shall remain in
effect until an acuity based registered nurse requirement is
promulgated by rule concurrent with the adoption of the
Resource Utilization Group classification-based payment
methodology, as provided in Section 5-5.2 of the Illinois
Public Aid Code. Registered nurses and licensed practical
nurses employed by a facility in excess of these requirements
may be used to satisfy the remaining 75% of the nursing and
personal care time requirements. Notwithstanding this
subsection, no staffing requirement in statute in effect on the
effective date of this amendatory Act of the 97th General
Assembly shall be reduced on account of this subsection.
(Source: P.A. 96-1372, eff. 7-29-10; 96-1504, eff. 1-27-11.)
 
    Section 50. The Emergency Medical Services (EMS) Systems
Act is amended by changing Section 3.86 as follows:
 
    (210 ILCS 50/3.86)
    Sec. 3.86. Stretcher van providers.
    (a) In this Section, "stretcher van provider" means an
entity licensed by the Department to provide non-emergency
transportation of passengers on a stretcher in compliance with
this Act or the rules adopted by the Department pursuant to
this Act, utilizing stretcher vans.
    (b) The Department has the authority and responsibility to
do the following:
        (1) Require all stretcher van providers, both publicly
    and privately owned, to be licensed by the Department.
        (2) Establish licensing and safety standards and
    requirements for stretcher van providers, through rules
    adopted pursuant to this Act, including but not limited to:
            (A) Vehicle design, specification, operation, and
        maintenance standards.
            (B) Safety equipment requirements and standards.
            (C) Staffing requirements.
            (D) Annual license renewal.
        (3) License all stretcher van providers that have met
    the Department's requirements for licensure.
        (4) Annually inspect all licensed stretcher van
    providers, and relicense providers that have met the
    Department's requirements for license renewal.
        (5) Suspend, revoke, refuse to issue, or refuse to
    renew the license of any stretcher van provider, or that
    portion of a license pertaining to a specific vehicle
    operated by a provider, after an opportunity for a hearing,
    when findings show that the provider or one or more of its
    vehicles has failed to comply with the standards and
    requirements of this Act or the rules adopted by the
    Department pursuant to this Act.
        (6) Issue an emergency suspension order for any
    provider or vehicle licensed under this Act when the
    Director or his or her designee has determined that an
    immediate or serious danger to the public health, safety,
    and welfare exists. Suspension or revocation proceedings
    that offer an opportunity for a hearing shall be promptly
    initiated after the emergency suspension order has been
    issued.
        (7) Prohibit any stretcher van provider from
    advertising, identifying its vehicles, or disseminating
    information in a false or misleading manner concerning the
    provider's type and level of vehicles, location, response
    times, level of personnel, licensure status, or EMS System
    participation.
        (8) Charge each stretcher van provider a fee, to be
    submitted with each application for licensure and license
    renewal.
    (c) A stretcher van provider may provide transport of a
passenger on a stretcher, provided the passenger meets all of
the following requirements:
        (1) (Blank). He or she needs no medical equipment,
    except self-administered medications.
        (2) He or she needs no medical monitoring or clinical
    observation medical observation.
        (3) He or she needs routine transportation to or from a
    medical appointment or service if the passenger is
    convalescent or otherwise bed-confined and does not
    require clinical observation medical monitoring, aid,
    care, or treatment during transport.
    (d) A stretcher van provider may not transport a passenger
who meets any of the following conditions:
        (1) He or she is being transported to a hospital for
    emergency medical treatment. He or she is currently
    admitted to a hospital or is being transported to a
    hospital for admission or emergency treatment.
        (2) He or she is experiencing an emergency medical
    condition or needs active medical monitoring, including
    isolation precautions, supplemental oxygen that is not
    self-administered, continuous airway management,
    suctioning during transport, or the administration of
    intravenous fluids during transport. He or she is acutely
    ill, wounded, or medically unstable as determined by a
    licensed physician.
        (3) He or she is experiencing an emergency medical
    condition, an acute medical condition, an exacerbation of a
    chronic medical condition, or a sudden illness or injury.
        (4) He or she was administered a medication that might
    prevent the passenger from caring for himself or herself.
        (5) He or she was moved from one environment where
    24-hour medical monitoring or medical observation will
    take place by certified or licensed nursing personnel to
    another such environment. Such environments shall include,
    but not be limited to, hospitals licensed under the
    Hospital Licensing Act or operated under the University of
    Illinois Hospital Act, and nursing facilities licensed
    under the Nursing Home Care Act.
    (e) The Stretcher Van Licensure Fund is created as a
special fund within the State treasury. All fees received by
the Department in connection with the licensure of stretcher
van providers under this Section shall be deposited into the
fund. Moneys in the fund shall be subject to appropriation to
the Department for use in implementing this Section.
(Source: P.A. 96-702, eff. 8-25-09; 96-1469, eff. 1-1-11.)
 
    Section 53. The Long Term Acute Care Hospital Quality
Improvement Transfer Program Act is amended by changing
Sections 35, 40, and 45 and by adding Section 55 as follows:
 
    (210 ILCS 155/35)
    Sec. 35. LTAC supplemental per diem rate.
    (a) The Department must pay an LTAC supplemental per diem
rate calculated under this Section to LTAC hospitals that meet
the requirements of Section 15 of this Act for patients:
        (1) who upon admission to the LTAC hospital meet LTAC
    hospital criteria; and
        (2) whose care is primarily paid for by the Department
    under Title XIX of the Social Security Act or whose care is
    primarily paid for by the Department after the patient has
    exhausted his or her benefits under Medicare.
    (b) The Department must not pay the LTAC supplemental per
diem rate calculated under this Section if any of the following
conditions are met:
        (1) the LTAC hospital no longer meets the requirements
    under Section 15 of this Act or terminates the agreement
    specified under Section 15 of this Act;
        (2) the patient does not meet the LTAC hospital
    criteria upon admission; or
        (3) the patient's care is primarily paid for by
    Medicare and the patient has not exhausted his or her
    Medicare benefits, resulting in the Department becoming
    the primary payer.
    (c) The Department may adjust the LTAC supplemental per
diem rate calculated under this Section based only on the
conditions and requirements described under Section 40 and
Section 45 of this Act.
    (d) The LTAC supplemental per diem rate shall be calculated
using the LTAC hospital's inflated cost per diem, defined in
subsection (f) of this Section, and subtracting the following:
        (1) The LTAC hospital's Medicaid per diem inpatient
    rate as calculated under 89 Ill. Adm. Code 148.270(c)(4).
        (2) The LTAC hospital's disproportionate share (DSH)
    rate as calculated under 89 Ill. Adm. Code 148.120.
        (3) The LTAC hospital's Medicaid Percentage Adjustment
    (MPA) rate as calculated under 89 Ill. Adm. Code 148.122.
        (4) The LTAC hospital's Medicaid High Volume
    Adjustment (MHVA) rate as calculated under 89 Ill. Adm.
    Code 148.290(d).
    (e) LTAC supplemental per diem rates are effective July 1,
2012 shall be the amount in effect as of October 1, 2010. No
new hospital may qualify for the program after the effective
date of this amendatory Act of the 97th General Assembly for 12
months beginning on October 1 of each year and must be updated
every 12 months.
    (f) For the purposes of this Section, "inflated cost per
diem" means the quotient resulting from dividing the hospital's
inpatient Medicaid costs by the hospital's Medicaid inpatient
days and inflating it to the most current period using
methodologies consistent with the calculation of the rates
described in paragraphs (2), (3), and (4) of subsection (d).
The data is obtained from the LTAC hospital's most recent cost
report submitted to the Department as mandated under 89 Ill.
Adm. Code 148.210.
    (g) On and after July 1, 2012, the Department shall reduce
any rate of reimbursement for services or other payments or
alter any methodologies authorized by this Act or the Illinois
Public Aid Code to reduce any rate of reimbursement for
services or other payments in accordance with Section 5-5e of
the Illinois Public Aid Code.
(Source: P.A. 96-1130, eff. 7-20-10.)
 
    (210 ILCS 155/40)
    Sec. 40. Rate adjustments for quality measures.
    (a) The Department may adjust the LTAC supplemental per
diem rate calculated under Section 35 of this Act based on the
requirements of this Section.
    (b) After the first year of operation of the Program
established by this Act, the Department may reduce the LTAC
supplemental per diem rate calculated under Section 35 of this
Act by no more than 5% for an LTAC hospital that does not meet
benchmarks or targets set by the Department under paragraph (2)
of subsection (b) of Section 50.
    (c) After the first year of operation of the Program
established by this Act, the Department may increase the LTAC
supplemental per diem rate calculated under Section 35 of this
Act by no more than 5% for an LTAC hospital that exceeds the
benchmarks or targets set by the Department under paragraph (2)
of subsection (a) of Section 50.
    (d) If an LTAC hospital misses a majority of the benchmarks
for quality measures for 3 consecutive years, the Department
may reduce the LTAC supplemental per diem rate calculated under
Section 35 of this Act to zero.
    (e) An LTAC hospital whose rate is reduced under subsection
(d) of this Section may have the LTAC supplemental per diem
rate calculated under Section 35 of this Act reinstated once
the LTAC hospital achieves the necessary benchmarks or targets.
    (f) The Department may apply the reduction described in
subsection (d) of this Section after one year instead of 3 to
an LTAC hospital that has had its rate previously reduced under
subsection (d) of this Section and later has had it reinstated
under subsection (e) of this Section.
    (g) The rate adjustments described in this Section shall be
determined and applied only at the beginning of each rate year.
    (h) On and after July 1, 2012, the Department shall reduce
any rate of reimbursement for services or other payments or
alter any methodologies authorized by this Act or the Illinois
Public Aid Code to reduce any rate of reimbursement for
services or other payments in accordance with Section 5-5e of
the Illinois Public Aid Code.
(Source: P.A. 96-1130, eff. 7-20-10.)
 
    (210 ILCS 155/45)
    Sec. 45. Program evaluation.
    (a) By After the Program completes the 3rd full year of
operation on September 30, 2012 2013, the Department must
complete an evaluation of the Program to determine the actual
savings or costs generated by the Program, both on an aggregate
basis and on an LTAC hospital-specific basis. The evaluation
must be conducted in each subsequent year.
    (b) The Department shall consult with and qualified LTAC
hospitals to must determine the appropriate methodology to
accurately calculate the Program's savings and costs. The
calculation shall take into consideration, but shall not be
limited to, the length of stay in an acute care hospital prior
to transfer, the length of stay in the LTAC taking into account
the acuity of the patient at the time of the LTAC admission,
and admissions to the LTAC from settings other than an STAC
hospital.
    (c) The evaluation must also determine the effects the
Program has had in improving patient satisfaction and health
outcomes.
    (d) If the evaluation indicates that the Program generates
a net cost to the Department, the Department may prospectively
adjust an individual hospital's LTAC supplemental per diem rate
under Section 35 of this Act to establish cost neutrality. The
rate adjustments applied under this subsection (d) do not need
to be applied uniformly to all qualified LTAC hospitals as long
as the adjustments are based on data from the evaluation on
hospital-specific information. Cost neutrality under this
Section means that the cost to the Department resulting from
the LTAC supplemental per diem rate must not exceed the savings
generated from transferring the patient from a STAC hospital.
    (e) The rate adjustment described in subsection (d) of this
Section, if necessary, shall be applied to the LTAC
supplemental per diem rate for the rate year beginning October
1, 2014. The Department may apply this rate adjustment in
subsequent rate years if the conditions under subsection (d) of
this Section are met. The Department must apply the rate
adjustment to an individual LTAC hospital's LTAC supplemental
per diem rate only in years when the Program evaluation
indicates a net cost for the Department.
    (f) The Department may establish a shared savings program
for qualified LTAC hospitals. The rate adjustments described in
this Section shall be determined and applied only at the
beginning of each rate year.
(Source: P.A. 96-1130, eff. 7-20-10.)
 
    (210 ILCS 155/55 new)
    Sec. 55. Demonstration care coordination program for
post-acute care.
    (a) The Department may develop a demonstration care
coordination program for LTAC hospital appropriate patients
with the goal of improving the continuum of care for patients
who have been discharged from an LTAC hospital.
    (b) The program shall require risk-sharing and quality
targets.
 
    Section 65. The Children's Health Insurance Program Act is
amended by changing Sections 25 and 40 as follows:
 
    (215 ILCS 106/25)
    Sec. 25. Health benefits for children.
    (a) The Department shall, subject to appropriation,
provide health benefits coverage to eligible children by:
        (1) Subsidizing the cost of privately sponsored health
    insurance, including employer based health insurance, to
    assist families to take advantage of available privately
    sponsored health insurance for their eligible children;
    and
        (2) Purchasing or providing health care benefits for
    eligible children. The health benefits provided under this
    subdivision (a)(2) shall, subject to appropriation and
    without regard to any applicable cost sharing under Section
    30, be identical to the benefits provided for children
    under the State's approved plan under Title XIX of the
    Social Security Act. Providers under this subdivision
    (a)(2) shall be subject to approval by the Department to
    provide health care under the Illinois Public Aid Code and
    shall be reimbursed at the same rate as providers under the
    State's approved plan under Title XIX of the Social
    Security Act. In addition, providers may retain
    co-payments when determined appropriate by the Department.
    (b) The subsidization provided pursuant to subdivision
(a)(1) shall be credited to the family of the eligible child.
    (c) The Department is prohibited from denying coverage to a
child who is enrolled in a privately sponsored health insurance
plan pursuant to subdivision (a)(1) because the plan does not
meet federal benchmarking standards or cost sharing and
contribution requirements. To be eligible for inclusion in the
Program, the plan shall contain comprehensive major medical
coverage which shall consist of physician and hospital
inpatient services. The Department is prohibited from denying
coverage to a child who is enrolled in a privately sponsored
health insurance plan pursuant to subdivision (a)(1) because
the plan offers benefits in addition to physician and hospital
inpatient services.
    (d) The total dollar amount of subsidizing coverage per
child per month pursuant to subdivision (a)(1) shall be equal
to the average dollar payments, less premiums incurred, per
child per month pursuant to subdivision (a)(2). The Department
shall set this amount prospectively based upon the prior fiscal
year's experience adjusted for incurred but not reported claims
and estimated increases or decreases in the cost of medical
care. Payments obligated before July 1, 1999, will be computed
using State Fiscal Year 1996 payments for children eligible for
Medical Assistance and income assistance under the Aid to
Families with Dependent Children Program, with appropriate
adjustments for cost and utilization changes through January 1,
1999. The Department is prohibited from providing a subsidy
pursuant to subdivision (a)(1) that is more than the
individual's monthly portion of the premium.
    (e) An eligible child may obtain immediate coverage under
this Program only once during a medical visit. If coverage
lapses, re-enrollment shall be completed in advance of the next
covered medical visit and the first month's required premium
shall be paid in advance of any covered medical visit.
    (f) In order to accelerate and facilitate the development
of networks to deliver services to children in areas outside
counties with populations in excess of 3,000,000, in the event
less than 25% of the eligible children in a county or
contiguous counties has enrolled with a Health Maintenance
Organization pursuant to Section 5-11 of the Illinois Public
Aid Code, the Department may develop and implement
demonstration projects to create alternative networks designed
to enhance enrollment and participation in the program. The
Department shall prescribe by rule the criteria, standards, and
procedures for effecting demonstration projects under this
Section.
    (g) On and after July 1, 2012, the Department shall reduce
any rate of reimbursement for services or other payments or
alter any methodologies authorized by this Act or the Illinois
Public Aid Code to reduce any rate of reimbursement for
services or other payments in accordance with Section 5-5e of
the Illinois Public Aid Code.
(Source: P.A. 90-736, eff. 8-12-98.)
 
    (215 ILCS 106/40)
    Sec. 40. Waivers. (a) The Department shall request any
necessary waivers of federal requirements in order to allow
receipt of federal funding. for:
        (1) the coverage of families with eligible children
    under this Act; and
        (2) the coverage of children who would otherwise be
    eligible under this Act, but who have health insurance.
    (b) The failure of the responsible federal agency to
approve a waiver for children who would otherwise be eligible
under this Act but who have health insurance shall not prevent
the implementation of any Section of this Act provided that
there are sufficient appropriated funds.
    (c) Eligibility of a person under an approved waiver due to
the relationship with a child pursuant to Article V of the
Illinois Public Aid Code or this Act shall be limited to such a
person whose countable income is determined by the Department
to be at or below such income eligibility standard as the
Department by rule shall establish. The income level
established by the Department shall not be below 90% of the
federal poverty level. Such persons who are determined to be
eligible must reapply, or otherwise establish eligibility, at
least annually. An eligible person shall be required, as
determined by the Department by rule, to report promptly those
changes in income and other circumstances that affect
eligibility. The eligibility of a person may be redetermined
based on the information reported or may be terminated based on
the failure to report or failure to report accurately. A person
may also be held liable to the Department for any payments made
by the Department on such person's behalf that were
inappropriate. An applicant shall be provided with notice of
these obligations.
(Source: P.A. 96-328, eff. 8-11-09.)
 
    Section 70. The Covering ALL KIDS Health Insurance Act is
amended by changing Sections 30 and 35 as follows:
 
    (215 ILCS 170/30)
    (Section scheduled to be repealed on July 1, 2016)
    Sec. 30. Program outreach and marketing. The Department may
provide grants to application agents and other community-based
organizations to educate the public about the availability of
the Program. The Department shall adopt rules regarding
performance standards and outcomes measures expected of
organizations that are awarded grants under this Section,
including penalties for nonperformance of contract standards.
    The Department shall annually publish electronically on a
State website and in no less than 2 newspapers in the State the
premiums or other cost sharing requirements of the Program.
(Source: P.A. 94-693, eff. 7-1-06; 95-985, eff. 6-1-09.)
 
    (215 ILCS 170/35)
    (Section scheduled to be repealed on July 1, 2016)
    Sec. 35. Health care benefits for children.
    (a) The Department shall purchase or provide health care
benefits for eligible children that are identical to the
benefits provided for children under the Illinois Children's
Health Insurance Program Act, except for non-emergency
transportation.
    (b) As an alternative to the benefits set forth in
subsection (a), and when cost-effective, the Department may
offer families subsidies toward the cost of privately sponsored
health insurance, including employer-sponsored health
insurance.
    (c) Notwithstanding clause (i) of subdivision (a)(3) of
Section 20, the Department may consider offering, as an
alternative to the benefits set forth in subsection (a),
partial coverage to children who are enrolled in a
high-deductible private health insurance plan.
    (d) Notwithstanding clause (i) of subdivision (a)(3) of
Section 20, the Department may consider offering, as an
alternative to the benefits set forth in subsection (a), a
limited package of benefits to children in families who have
private or employer-sponsored health insurance that does not
cover certain benefits such as dental or vision benefits.
    (e) The content and availability of benefits described in
subsections (b), (c), and (d), and the terms of eligibility for
those benefits, shall be at the Department's discretion and the
Department's determination of efficacy and cost-effectiveness
as a means of promoting retention of private or
employer-sponsored health insurance.
    (f) On and after July 1, 2012, the Department shall reduce
any rate of reimbursement for services or other payments or
alter any methodologies authorized by this Act or the Illinois
Public Aid Code to reduce any rate of reimbursement for
services or other payments in accordance with Section 5-5e of
the Illinois Public Aid Code.
(Source: P.A. 94-693, eff. 7-1-06.)
 
    Section 75. The Illinois Public Aid Code is amended by
changing Sections 3-1.2, 5-2, 5-4, 5-4.1, 5-4.2, 5-5, 5-5.02,
5-5.05, 5-5.2, 5-5.3, 5-5.4, 5-5.4e, 5-5.5, 5-5.8b, 5-5.12,
5-5.17, 5-5.20, 5-5.23, 5-5.24, 5-5.25, 5-16.7, 5-16.7a,
5-16.8, 5-16.9, 5-17, 5-19, 5-24, 5-30, 5A-1, 5A-2, 5A-3, 5A-4,
5A-5, 5A-6, 5A-8, 5A-10, 5A-12.2, 5A-14, 6-11, 11-13, 11-26,
12-4.25, 12-4.38, 12-4.39, 12-10.5, 12-13.1, 14-8, and 15-1 and
by adding Sections 5-2b, 5-2.1d, 5-5e, 5-5e.1, 5-5f, 5A-15,
11-5.2, 11-5.3, and 14-11 as follows:
 
    (305 ILCS 5/3-1.2)  (from Ch. 23, par. 3-1.2)
    Sec. 3-1.2. Need. Income available to the person, when
added to contributions in money, substance, or services from
other sources, including contributions from legally
responsible relatives, must be insufficient to equal the grant
amount established by Department regulation for such person.
    In determining earned income to be taken into account,
consideration shall be given to any expenses reasonably
attributable to the earning of such income. If federal law or
regulations permit or require exemption of earned or other
income and resources, the Illinois Department shall provide by
rule and regulation that the amount of income to be disregarded
be increased (1) to the maximum extent so required and (2) to
the maximum extent permitted by federal law or regulation in
effect as of the date this Amendatory Act becomes law. The
Illinois Department may also provide by rule and regulation
that the amount of resources to be disregarded be increased to
the maximum extent so permitted or required. Subject to federal
approval, resources (for example, land, buildings, equipment,
supplies, or tools), including farmland property and personal
property used in the income-producing operations related to the
farmland (for example, equipment and supplies, motor vehicles,
or tools), necessary for self-support, up to $6,000 of the
person's equity in the income-producing property, provided
that the property produces a net annual income of at least 6%
of the excluded equity value of the property, are exempt.
Equity value in excess of $6,000 shall not be excluded if the
activity produces income that is less than 6% of the exempt
equity due to reasons beyond the person's control (for example,
the person's illness or crop failure) and there is a reasonable
expectation that the property will again produce income equal
to or greater than 6% of the equity value (for example, a
medical prognosis that the person is expected to respond to
treatment or that drought-resistant corn will be planted). If
the person owns more than one piece of property and each
produces income, each piece of property shall be looked at to
determine whether the 6% rule is met, and then the amounts of
the person's equity in all of those properties shall be totaled
to determine whether the total equity is $6,000 or less. The
total equity value of all properties that is exempt shall be
limited to $6,000.
    In determining the resources of an individual or any
dependents, the Department shall exclude from consideration
the value of funeral and burial spaces, grave markers and other
funeral and burial merchandise, funeral and burial insurance
the proceeds of which can only be used to pay the funeral and
burial expenses of the insured and funds specifically set aside
for the funeral and burial arrangements of the individual or
his or her dependents, including prepaid funeral and burial
plans, to the same extent that such items are excluded from
consideration under the federal Supplemental Security Income
program (SSI).
    Prepaid funeral or burial contracts are exempt to the
following extent:
        (1) Funds in a revocable prepaid funeral or burial
    contract are exempt up to $1,500, except that any portion
    of a contract that clearly represents the purchase of
    burial space, as that term is defined for purposes of the
    Supplemental Security Income program, is exempt regardless
    of value.
        (2) Funds in an irrevocable prepaid funeral or burial
    contract are exempt up to $5,874, except that any portion
    of a contract that clearly represents the purchase of
    burial space, as that term is defined for purposes of the
    Supplemental Security Income program, is exempt regardless
    of value. This amount shall be adjusted annually for any
    increase in the Consumer Price Index. The amount exempted
    shall be limited to the price of the funeral goods and
    services to be provided upon death. The contract must
    provide a complete description of the funeral goods and
    services to be provided and the price thereof. Any amount
    in the contract not so specified shall be treated as a
    transfer of assets for less than fair market value.
        (3) A prepaid, guaranteed-price funeral or burial
    contract, funded by an irrevocable assignment of a person's
    life insurance policy to a trust, is exempt. The amount
    exempted shall be limited to the amount of the insurance
    benefit designated for the cost of the funeral goods and
    services to be provided upon the person's death. The
    contract must provide a complete description of the funeral
    goods and services to be provided and the price thereof.
    Any amount in the contract not so specified shall be
    treated as a transfer of assets for less than fair market
    value. The trust must include a statement that, upon the
    death of the person, the State will receive all amounts
    remaining in the trust, including any remaining payable
    proceeds under the insurance policy up to an amount equal
    to the total medical assistance paid on behalf of the
    person. The trust is responsible for ensuring that the
    provider of funeral services under the contract receives
    the proceeds of the policy when it provides the funeral
    goods and services specified under the contract. The
    irrevocable assignment of ownership of the insurance
    policy must be acknowledged by the insurance company.
    Notwithstanding any other provision of this Code to the
contrary, an irrevocable trust containing the resources of a
person who is determined to have a disability shall be
considered exempt from consideration. Such trust must be
established and managed by a non-profit association that pools
funds but maintains a separate account for each beneficiary.
The trust may be established by the person, a parent,
grandparent, legal guardian, or court. It must be established
for the sole benefit of the person and language contained in
the trust shall stipulate that any amount remaining in the
trust (up to the amount expended by the Department on medical
assistance) that is not retained by the trust for reasonable
administrative costs related to wrapping up the affairs of the
subaccount shall be paid to the Department upon the death of
the person. After a person reaches age 65, any funding by or on
behalf of the person to the trust shall be treated as a
transfer of assets for less than fair market value unless the
person is a ward of a county public guardian or the State
guardian pursuant to Section 13-5 of the Probate Act of 1975 or
Section 30 of the Guardianship and Advocacy Act and lives in
the community, or the person is a ward of a county public
guardian or the State guardian pursuant to Section 13-5 of the
Probate Act of 1975 or Section 30 of the Guardianship and
Advocacy Act and a court has found that any expenditures from
the trust will maintain or enhance the person's quality of
life. If the trust contains proceeds from a personal injury
settlement, any Department charge must be satisfied in order
for the transfer to the trust to be treated as a transfer for
fair market value.
    The homestead shall be exempt from consideration except to
the extent that it meets the income and shelter needs of the
person. "Homestead" means the dwelling house and contiguous
real estate owned and occupied by the person, regardless of its
value. Subject to federal approval, a person shall not be
eligible for long-term care services, however, if the person's
equity interest in his or her homestead exceeds the minimum
home equity as allowed and increased annually under federal
law. Subject to federal approval, on and after the effective
date of this amendatory Act of the 97th General Assembly,
homestead property transferred to a trust shall no longer be
considered homestead property.
    Occasional or irregular gifts in cash, goods or services
from persons who are not legally responsible relatives which
are of nominal value or which do not have significant effect in
meeting essential requirements shall be disregarded. The
eligibility of any applicant for or recipient of public aid
under this Article is not affected by the payment of any grant
under the "Senior Citizens and Disabled Persons Property Tax
Relief and Pharmaceutical Assistance Act" or any distributions
or items of income described under subparagraph (X) of
paragraph (2) of subsection (a) of Section 203 of the Illinois
Income Tax Act.
    The Illinois Department may, after appropriate
investigation, establish and implement a consolidated standard
to determine need and eligibility for and amount of benefits
under this Article or a uniform cash supplement to the federal
Supplemental Security Income program for all or any part of the
then current recipients under this Article; provided, however,
that the establishment or implementation of such a standard or
supplement shall not result in reductions in benefits under
this Article for the then current recipients of such benefits.
(Source: P.A. 91-676, eff. 12-23-99.)
 
    (305 ILCS 5/5-2)  (from Ch. 23, par. 5-2)
    Sec. 5-2. Classes of Persons Eligible. Medical assistance
under this Article shall be available to any of the following
classes of persons in respect to whom a plan for coverage has
been submitted to the Governor by the Illinois Department and
approved by him:
        1. Recipients of basic maintenance grants under
    Articles III and IV.
        2. Persons otherwise eligible for basic maintenance
    under Articles III and IV, excluding any eligibility
    requirements that are inconsistent with any federal law or
    federal regulation, as interpreted by the U.S. Department
    of Health and Human Services, but who fail to qualify
    thereunder on the basis of need or who qualify but are not
    receiving basic maintenance under Article IV, and who have
    insufficient income and resources to meet the costs of
    necessary medical care, including but not limited to the
    following:
            (a) All persons otherwise eligible for basic
        maintenance under Article III but who fail to qualify
        under that Article on the basis of need and who meet
        either of the following requirements:
                (i) their income, as determined by the
            Illinois Department in accordance with any federal
            requirements, is equal to or less than 70% in
            fiscal year 2001, equal to or less than 85% in
            fiscal year 2002 and until a date to be determined
            by the Department by rule, and equal to or less
            than 100% beginning on the date determined by the
            Department by rule, of the nonfarm income official
            poverty line, as defined by the federal Office of
            Management and Budget and revised annually in
            accordance with Section 673(2) of the Omnibus
            Budget Reconciliation Act of 1981, applicable to
            families of the same size; or
                (ii) their income, after the deduction of
            costs incurred for medical care and for other types
            of remedial care, is equal to or less than 70% in
            fiscal year 2001, equal to or less than 85% in
            fiscal year 2002 and until a date to be determined
            by the Department by rule, and equal to or less
            than 100% beginning on the date determined by the
            Department by rule, of the nonfarm income official
            poverty line, as defined in item (i) of this
            subparagraph (a).
            (b) All persons who, excluding any eligibility
        requirements that are inconsistent with any federal
        law or federal regulation, as interpreted by the U.S.
        Department of Health and Human Services, would be
        determined eligible for such basic maintenance under
        Article IV by disregarding the maximum earned income
        permitted by federal law.
        3. Persons who would otherwise qualify for Aid to the
    Medically Indigent under Article VII.
        4. Persons not eligible under any of the preceding
    paragraphs who fall sick, are injured, or die, not having
    sufficient money, property or other resources to meet the
    costs of necessary medical care or funeral and burial
    expenses.
        5.(a) Women during pregnancy, after the fact of
    pregnancy has been determined by medical diagnosis, and
    during the 60-day period beginning on the last day of the
    pregnancy, together with their infants and children born
    after September 30, 1983, whose income and resources are
    insufficient to meet the costs of necessary medical care to
    the maximum extent possible under Title XIX of the Federal
    Social Security Act.
        (b) The Illinois Department and the Governor shall
    provide a plan for coverage of the persons eligible under
    paragraph 5(a) by April 1, 1990. Such plan shall provide
    ambulatory prenatal care to pregnant women during a
    presumptive eligibility period and establish an income
    eligibility standard that is equal to 133% of the nonfarm
    income official poverty line, as defined by the federal
    Office of Management and Budget and revised annually in
    accordance with Section 673(2) of the Omnibus Budget
    Reconciliation Act of 1981, applicable to families of the
    same size, provided that costs incurred for medical care
    are not taken into account in determining such income
    eligibility.
        (c) The Illinois Department may conduct a
    demonstration in at least one county that will provide
    medical assistance to pregnant women, together with their
    infants and children up to one year of age, where the
    income eligibility standard is set up to 185% of the
    nonfarm income official poverty line, as defined by the
    federal Office of Management and Budget. The Illinois
    Department shall seek and obtain necessary authorization
    provided under federal law to implement such a
    demonstration. Such demonstration may establish resource
    standards that are not more restrictive than those
    established under Article IV of this Code.
        6. Persons under the age of 18 who fail to qualify as
    dependent under Article IV and who have insufficient income
    and resources to meet the costs of necessary medical care
    to the maximum extent permitted under Title XIX of the
    Federal Social Security Act.
        7. (Blank). Persons who are under 21 years of age and
    would qualify as disabled as defined under the Federal
    Supplemental Security Income Program, provided medical
    service for such persons would be eligible for Federal
    Financial Participation, and provided the Illinois
    Department determines that:
            (a) the person requires a level of care provided by
        a hospital, skilled nursing facility, or intermediate
        care facility, as determined by a physician licensed to
        practice medicine in all its branches;
            (b) it is appropriate to provide such care outside
        of an institution, as determined by a physician
        licensed to practice medicine in all its branches;
            (c) the estimated amount which would be expended
        for care outside the institution is not greater than
        the estimated amount which would be expended in an
        institution.
        8. Persons who become ineligible for basic maintenance
    assistance under Article IV of this Code in programs
    administered by the Illinois Department due to employment
    earnings and persons in assistance units comprised of
    adults and children who become ineligible for basic
    maintenance assistance under Article VI of this Code due to
    employment earnings. The plan for coverage for this class
    of persons shall:
            (a) extend the medical assistance coverage for up
        to 12 months following termination of basic
        maintenance assistance; and
            (b) offer persons who have initially received 6
        months of the coverage provided in paragraph (a) above,
        the option of receiving an additional 6 months of
        coverage, subject to the following:
                (i) such coverage shall be pursuant to
            provisions of the federal Social Security Act;
                (ii) such coverage shall include all services
            covered while the person was eligible for basic
            maintenance assistance;
                (iii) no premium shall be charged for such
            coverage; and
                (iv) such coverage shall be suspended in the
            event of a person's failure without good cause to
            file in a timely fashion reports required for this
            coverage under the Social Security Act and
            coverage shall be reinstated upon the filing of
            such reports if the person remains otherwise
            eligible.
        9. Persons with acquired immunodeficiency syndrome
    (AIDS) or with AIDS-related conditions with respect to whom
    there has been a determination that but for home or
    community-based services such individuals would require
    the level of care provided in an inpatient hospital,
    skilled nursing facility or intermediate care facility the
    cost of which is reimbursed under this Article. Assistance
    shall be provided to such persons to the maximum extent
    permitted under Title XIX of the Federal Social Security
    Act.
        10. Participants in the long-term care insurance
    partnership program established under the Illinois
    Long-Term Care Partnership Program Act who meet the
    qualifications for protection of resources described in
    Section 15 of that Act.
        11. Persons with disabilities who are employed and
    eligible for Medicaid, pursuant to Section
    1902(a)(10)(A)(ii)(xv) of the Social Security Act, and,
    subject to federal approval, persons with a medically
    improved disability who are employed and eligible for
    Medicaid pursuant to Section 1902(a)(10)(A)(ii)(xvi) of
    the Social Security Act, as provided by the Illinois
    Department by rule. In establishing eligibility standards
    under this paragraph 11, the Department shall, subject to
    federal approval:
            (a) set the income eligibility standard at not
        lower than 350% of the federal poverty level;
            (b) exempt retirement accounts that the person
        cannot access without penalty before the age of 59 1/2,
        and medical savings accounts established pursuant to
        26 U.S.C. 220;
            (c) allow non-exempt assets up to $25,000 as to
        those assets accumulated during periods of eligibility
        under this paragraph 11; and
            (d) continue to apply subparagraphs (b) and (c) in
        determining the eligibility of the person under this
        Article even if the person loses eligibility under this
        paragraph 11.
        12. Subject to federal approval, persons who are
    eligible for medical assistance coverage under applicable
    provisions of the federal Social Security Act and the
    federal Breast and Cervical Cancer Prevention and
    Treatment Act of 2000. Those eligible persons are defined
    to include, but not be limited to, the following persons:
            (1) persons who have been screened for breast or
        cervical cancer under the U.S. Centers for Disease
        Control and Prevention Breast and Cervical Cancer
        Program established under Title XV of the federal
        Public Health Services Act in accordance with the
        requirements of Section 1504 of that Act as
        administered by the Illinois Department of Public
        Health; and
            (2) persons whose screenings under the above
        program were funded in whole or in part by funds
        appropriated to the Illinois Department of Public
        Health for breast or cervical cancer screening.
        "Medical assistance" under this paragraph 12 shall be
    identical to the benefits provided under the State's
    approved plan under Title XIX of the Social Security Act.
    The Department must request federal approval of the
    coverage under this paragraph 12 within 30 days after the
    effective date of this amendatory Act of the 92nd General
    Assembly.
        In addition to the persons who are eligible for medical
    assistance pursuant to subparagraphs (1) and (2) of this
    paragraph 12, and to be paid from funds appropriated to the
    Department for its medical programs, any uninsured person
    as defined by the Department in rules residing in Illinois
    who is younger than 65 years of age, who has been screened
    for breast and cervical cancer in accordance with standards
    and procedures adopted by the Department of Public Health
    for screening, and who is referred to the Department by the
    Department of Public Health as being in need of treatment
    for breast or cervical cancer is eligible for medical
    assistance benefits that are consistent with the benefits
    provided to those persons described in subparagraphs (1)
    and (2). Medical assistance coverage for the persons who
    are eligible under the preceding sentence is not dependent
    on federal approval, but federal moneys may be used to pay
    for services provided under that coverage upon federal
    approval.
        13. Subject to appropriation and to federal approval,
    persons living with HIV/AIDS who are not otherwise eligible
    under this Article and who qualify for services covered
    under Section 5-5.04 as provided by the Illinois Department
    by rule.
        14. Subject to the availability of funds for this
    purpose, the Department may provide coverage under this
    Article to persons who reside in Illinois who are not
    eligible under any of the preceding paragraphs and who meet
    the income guidelines of paragraph 2(a) of this Section and
    (i) have an application for asylum pending before the
    federal Department of Homeland Security or on appeal before
    a court of competent jurisdiction and are represented
    either by counsel or by an advocate accredited by the
    federal Department of Homeland Security and employed by a
    not-for-profit organization in regard to that application
    or appeal, or (ii) are receiving services through a
    federally funded torture treatment center. Medical
    coverage under this paragraph 14 may be provided for up to
    24 continuous months from the initial eligibility date so
    long as an individual continues to satisfy the criteria of
    this paragraph 14. If an individual has an appeal pending
    regarding an application for asylum before the Department
    of Homeland Security, eligibility under this paragraph 14
    may be extended until a final decision is rendered on the
    appeal. The Department may adopt rules governing the
    implementation of this paragraph 14.
        15. Family Care Eligibility.
            (a) On and after July 1, 2012 Through December 31,
        2013, a caretaker relative who is 19 years of age or
        older when countable income is at or below 133% 185% of
        the Federal Poverty Level Guidelines, as published
        annually in the Federal Register, for the appropriate
        family size. Beginning January 1, 2014, a caretaker
        relative who is 19 years of age or older when countable
        income is at or below 133% of the Federal Poverty Level
        Guidelines, as published annually in the Federal
        Register, for the appropriate family size. A person may
        not spend down to become eligible under this paragraph
        15.
            (b) Eligibility shall be reviewed annually.
            (c) (Blank). Caretaker relatives enrolled under
        this paragraph 15 in families with countable income
        above 150% and at or below 185% of the Federal Poverty
        Level Guidelines shall be counted as family members and
        pay premiums as established under the Children's
        Health Insurance Program Act.
            (d) (Blank). Premiums shall be billed by and
        payable to the Department or its authorized agent, on a
        monthly basis.
            (e) (Blank). The premium due date is the last day
        of the month preceding the month of coverage.
            (f) (Blank). Individuals shall have a grace period
        through 60 days of coverage to pay the premium.
            (g) (Blank). Failure to pay the full monthly
        premium by the last day of the grace period shall
        result in termination of coverage.
            (h) (Blank). Partial premium payments shall not be
        refunded.
            (i) Following termination of an individual's
        coverage under this paragraph 15, the individual must
        be determined eligible before the person can be
        re-enrolled. following action is required before the
        individual can be re-enrolled:
                (1) A new application must be completed and the
            individual must be determined otherwise eligible.
                (2) There must be full payment of premiums due
            under this Code, the Children's Health Insurance
            Program Act, the Covering ALL KIDS Health
            Insurance Act, or any other healthcare program
            administered by the Department for periods in
            which a premium was owed and not paid for the
            individual.
                (3) The first month's premium must be paid if
            there was an unpaid premium on the date the
            individual's previous coverage was canceled.
        The Department is authorized to implement the
    provisions of this amendatory Act of the 95th General
    Assembly by adopting the medical assistance rules in effect
    as of October 1, 2007, at 89 Ill. Admin. Code 125, and at
    89 Ill. Admin. Code 120.32 along with only those changes
    necessary to conform to federal Medicaid requirements,
    federal laws, and federal regulations, including but not
    limited to Section 1931 of the Social Security Act (42
    U.S.C. Sec. 1396u-1), as interpreted by the U.S. Department
    of Health and Human Services, and the countable income
    eligibility standard authorized by this paragraph 15. The
    Department may not otherwise adopt any rule to implement
    this increase except as authorized by law, to meet the
    eligibility standards authorized by the federal government
    in the Medicaid State Plan or the Title XXI Plan, or to
    meet an order from the federal government or any court.
        16. Subject to appropriation, uninsured persons who
    are not otherwise eligible under this Section who have been
    certified and referred by the Department of Public Health
    as having been screened and found to need diagnostic
    evaluation or treatment, or both diagnostic evaluation and
    treatment, for prostate or testicular cancer. For the
    purposes of this paragraph 16, uninsured persons are those
    who do not have creditable coverage, as defined under the
    Health Insurance Portability and Accountability Act, or
    have otherwise exhausted any insurance benefits they may
    have had, for prostate or testicular cancer diagnostic
    evaluation or treatment, or both diagnostic evaluation and
    treatment. To be eligible, a person must furnish a Social
    Security number. A person's assets are exempt from
    consideration in determining eligibility under this
    paragraph 16. Such persons shall be eligible for medical
    assistance under this paragraph 16 for so long as they need
    treatment for the cancer. A person shall be considered to
    need treatment if, in the opinion of the person's treating
    physician, the person requires therapy directed toward
    cure or palliation of prostate or testicular cancer,
    including recurrent metastatic cancer that is a known or
    presumed complication of prostate or testicular cancer and
    complications resulting from the treatment modalities
    themselves. Persons who require only routine monitoring
    services are not considered to need treatment. "Medical
    assistance" under this paragraph 16 shall be identical to
    the benefits provided under the State's approved plan under
    Title XIX of the Social Security Act. Notwithstanding any
    other provision of law, the Department (i) does not have a
    claim against the estate of a deceased recipient of
    services under this paragraph 16 and (ii) does not have a
    lien against any homestead property or other legal or
    equitable real property interest owned by a recipient of
    services under this paragraph 16.
    In implementing the provisions of Public Act 96-20, the
Department is authorized to adopt only those rules necessary,
including emergency rules. Nothing in Public Act 96-20 permits
the Department to adopt rules or issue a decision that expands
eligibility for the FamilyCare Program to a person whose income
exceeds 185% of the Federal Poverty Level as determined from
time to time by the U.S. Department of Health and Human
Services, unless the Department is provided with express
statutory authority.
    The Illinois Department and the Governor shall provide a
plan for coverage of the persons eligible under paragraph 7 as
soon as possible after July 1, 1984.
    The eligibility of any such person for medical assistance
under this Article is not affected by the payment of any grant
under the Senior Citizens and Disabled Persons Property Tax
Relief and Pharmaceutical Assistance Act or any distributions
or items of income described under subparagraph (X) of
paragraph (2) of subsection (a) of Section 203 of the Illinois
Income Tax Act. The Department shall by rule establish the
amounts of assets to be disregarded in determining eligibility
for medical assistance, which shall at a minimum equal the
amounts to be disregarded under the Federal Supplemental
Security Income Program. The amount of assets of a single
person to be disregarded shall not be less than $2,000, and the
amount of assets of a married couple to be disregarded shall
not be less than $3,000.
    To the extent permitted under federal law, any person found
guilty of a second violation of Article VIIIA shall be
ineligible for medical assistance under this Article, as
provided in Section 8A-8.
    The eligibility of any person for medical assistance under
this Article shall not be affected by the receipt by the person
of donations or benefits from fundraisers held for the person
in cases of serious illness, as long as neither the person nor
members of the person's family have actual control over the
donations or benefits or the disbursement of the donations or
benefits.
(Source: P.A. 96-20, eff. 6-30-09; 96-181, eff. 8-10-09;
96-328, eff. 8-11-09; 96-567, eff. 1-1-10; 96-1000, eff.
7-2-10; 96-1123, eff. 1-1-11; 96-1270, eff. 7-26-10; 97-48,
eff. 6-28-11; 97-74, eff. 6-30-11; 97-333, eff. 8-12-11;
revised 10-4-11.)
 
    (305 ILCS 5/5-2b new)
    Sec. 5-2b. Medically fragile and technology dependent
children eligibility and program. Notwithstanding any other
provision of law, on and after September 1, 2012, subject to
federal approval, medical assistance under this Article shall
be available to children who qualify as persons with a
disability, as defined under the federal Supplemental Security
Income program and who are medically fragile and technology
dependent. The program shall allow eligible children to receive
the medical assistance provided under this Article in the
community, shall be limited to families with income up to 500%
of the federal poverty level, and must maximize, to the fullest
extent permissible under federal law, federal reimbursement
and family cost-sharing, including co-pays, premiums, or any
other family contributions, except that the Department shall be
permitted to incentivize the utilization of selected services
through the use of cost-sharing adjustments. The Department
shall establish the policies, procedures, standards, services,
and criteria for this program by rule.
 
    (305 ILCS 5/5-2.1d new)
    Sec. 5-2.1d. Retroactive eligibility. An applicant for
medical assistance may be eligible for up to 3 months prior to
the date of application if the person would have been eligible
for medical assistance at the time he or she received the
services if he or she had applied, regardless of whether the
individual is alive when the application for medical assistance
is made. In determining financial eligibility for medical
assistance for retroactive months, the Department shall
consider the amount of income and resources and exemptions
available to a person as of the first day of each of the
backdated months for which eligibility is sought.
 
    (305 ILCS 5/5-4)  (from Ch. 23, par. 5-4)
    Sec. 5-4. Amount and nature of medical assistance.
    (a) The amount and nature of medical assistance shall be
determined by the County Departments in accordance with the
standards, rules, and regulations of the Department of
Healthcare and Family Services, with due regard to the
requirements and conditions in each case, including
contributions available from legally responsible relatives.
However, the amount and nature of such medical assistance shall
not be affected by the payment of any grant under the Senior
Citizens and Disabled Persons Property Tax Relief and
Pharmaceutical Assistance Act or any distributions or items of
income described under subparagraph (X) of paragraph (2) of
subsection (a) of Section 203 of the Illinois Income Tax Act.
The amount and nature of medical assistance shall not be
affected by the receipt of donations or benefits from
fundraisers in cases of serious illness, as long as neither the
person nor members of the person's family have actual control
over the donations or benefits or the disbursement of the
donations or benefits.
    In determining the income and resources assets available to
the institutionalized spouse and to the community spouse, the
Department of Healthcare and Family Services shall follow the
procedures established by federal law. If an institutionalized
spouse or community spouse refuses to comply with the
requirements of Title XIX of the federal Social Security Act
and the regulations duly promulgated thereunder by failing to
provide the total value of assets, including income and
resources, to the extent either the institutionalized spouse or
community spouse has an ownership interest in them pursuant to
42 U.S.C. 1396r-5, such refusal may result in the
institutionalized spouse being denied eligibility and
continuing to remain ineligible for the medical assistance
program based on failure to cooperate.
    Subject to federal approval, the The community spouse
resource allowance shall be established and maintained at the
higher of $109,560 or the minimum maximum level permitted
pursuant to Section 1924(f)(2) of the Social Security Act, as
now or hereafter amended, or an amount set after a fair
hearing, whichever is greater. The monthly maintenance
allowance for the community spouse shall be established and
maintained at the higher of $2,739 per month or the minimum
maximum level permitted pursuant to Section 1924(d)(3)(C) of
the Social Security Act, as now or hereafter amended, or an
amount set after a fair hearing, whichever is greater. Subject
to the approval of the Secretary of the United States
Department of Health and Human Services, the provisions of this
Section shall be extended to persons who but for the provision
of home or community-based services under Section 4.02 of the
Illinois Act on the Aging, would require the level of care
provided in an institution, as is provided for in federal law.
    (b) Spousal support for institutionalized spouses
receiving medical assistance.
        (i) The Department may seek support for an
    institutionalized spouse, who has assigned his or her right
    of support from his or her spouse to the State, from the
    resources and income available to the community spouse.
        (ii) The Department may bring an action in the circuit
    court to establish support orders or itself establish
    administrative support orders by any means and procedures
    authorized in this Code, as applicable, except that the
    standard and regulations for determining ability to
    support in Section 10-3 shall not limit the amount of
    support that may be ordered.
        (iii) Proceedings may be initiated to obtain support,
    or for the recovery of aid granted during the period such
    support was not provided, or both, for the obtainment of
    support and the recovery of the aid provided. Proceedings
    for the recovery of aid may be taken separately or they may
    be consolidated with actions to obtain support. Such
    proceedings may be brought in the name of the person or
    persons requiring support or may be brought in the name of
    the Department, as the case requires.
        (iv) The orders for the payment of moneys for the
    support of the person shall be just and equitable and may
    direct payment thereof for such period or periods of time
    as the circumstances require, including support for a
    period before the date the order for support is entered. In
    no event shall the orders reduce the community spouse
    resource allowance below the level established in
    subsection (a) of this Section or an amount set after a
    fair hearing, whichever is greater, or reduce the monthly
    maintenance allowance for the community spouse below the
    level permitted pursuant to subsection (a) of this Section.
    The Department of Human Services shall notify in writing
each institutionalized spouse who is a recipient of medical
assistance under this Article, and each such person's community
spouse, of the changes in treatment of income and resources,
including provisions for protecting income for a community
spouse and permitting the transfer of resources to a community
spouse, required by enactment of the federal Medicare
Catastrophic Coverage Act of 1988 (Public Law 100-360). The
notification shall be in language likely to be easily
understood by those persons. The Department of Human Services
also shall reassess the amount of medical assistance for which
each such recipient is eligible as a result of the enactment of
that federal Act, whether or not a recipient requests such a
reassessment.
(Source: P.A. 95-331, eff. 8-21-07.)
 
    (305 ILCS 5/5-4.1)  (from Ch. 23, par. 5-4.1)
    Sec. 5-4.1. Co-payments. The Department may by rule provide
that recipients under any Article of this Code shall pay a fee
as a co-payment for services. Co-payments shall be maximized to
the extent permitted by federal law, except that the Department
shall impose a co-pay of $2 on generic drugs. Provided,
however, that any such rule must provide that no co-payment
requirement can exist for renal dialysis, radiation therapy,
cancer chemotherapy, or insulin, and other products necessary
on a recurring basis, the absence of which would be life
threatening, or where co-payment expenditures for required
services and/or medications for chronic diseases that the
Illinois Department shall by rule designate shall cause an
extensive financial burden on the recipient, and provided no
co-payment shall exist for emergency room encounters which are
for medical emergencies. The Department shall seek approval of
a State plan amendment that allows pharmacies to refuse to
dispense drugs in circumstances where the recipient does not
pay the required co-payment. In the event the State plan
amendment is rejected, co-payments may not exceed $3 for brand
name drugs, $1 for other pharmacy services other than for
generic drugs, and $2 for physician services, dental services,
optical services and supplies, chiropractic services, podiatry
services, and encounter rate clinic services. There shall be no
co-payment for generic drugs. Co-payments may not exceed $10
for emergency room use for a non-emergency situation as defined
by the Department by rule and subject to federal approval.
(Source: P.A. 96-1501, eff. 1-25-11; 97-74, eff. 6-30-11.)
 
    (305 ILCS 5/5-4.2)  (from Ch. 23, par. 5-4.2)
    Sec. 5-4.2. Ambulance services payments.
    (a) For ambulance services provided to a recipient of aid
under this Article on or after January 1, 1993, the Illinois
Department shall reimburse ambulance service providers at
rates calculated in accordance with this Section. It is the
intent of the General Assembly to provide adequate
reimbursement for ambulance services so as to ensure adequate
access to services for recipients of aid under this Article and
to provide appropriate incentives to ambulance service
providers to provide services in an efficient and
cost-effective manner. Thus, it is the intent of the General
Assembly that the Illinois Department implement a
reimbursement system for ambulance services that, to the extent
practicable and subject to the availability of funds
appropriated by the General Assembly for this purpose, is
consistent with the payment principles of Medicare. To ensure
uniformity between the payment principles of Medicare and
Medicaid, the Illinois Department shall follow, to the extent
necessary and practicable and subject to the availability of
funds appropriated by the General Assembly for this purpose,
the statutes, laws, regulations, policies, procedures,
principles, definitions, guidelines, and manuals used to
determine the amounts paid to ambulance service providers under
Title XVIII of the Social Security Act (Medicare).
    (b) For ambulance services provided to a recipient of aid
under this Article on or after January 1, 1996, the Illinois
Department shall reimburse ambulance service providers based
upon the actual distance traveled if a natural disaster,
weather conditions, road repairs, or traffic congestion
necessitates the use of a route other than the most direct
route.
    (c) For purposes of this Section, "ambulance services"
includes medical transportation services provided by means of
an ambulance, medi-car, service car, or taxi.
    (c-1) For purposes of this Section, "ground ambulance
service" means medical transportation services that are
described as ground ambulance services by the Centers for
Medicare and Medicaid Services and provided in a vehicle that
is licensed as an ambulance by the Illinois Department of
Public Health pursuant to the Emergency Medical Services (EMS)
Systems Act.
    (c-2) For purposes of this Section, "ground ambulance
service provider" means a vehicle service provider as described
in the Emergency Medical Services (EMS) Systems Act that
operates licensed ambulances for the purpose of providing
emergency ambulance services, or non-emergency ambulance
services, or both. For purposes of this Section, this includes
both ambulance providers and ambulance suppliers as described
by the Centers for Medicare and Medicaid Services.
    (d) This Section does not prohibit separate billing by
ambulance service providers for oxygen furnished while
providing advanced life support services.
    (e) Beginning with services rendered on or after July 1,
2008, all providers of non-emergency medi-car and service car
transportation must certify that the driver and employee
attendant, as applicable, have completed a safety program
approved by the Department to protect both the patient and the
driver, prior to transporting a patient. The provider must
maintain this certification in its records. The provider shall
produce such documentation upon demand by the Department or its
representative. Failure to produce documentation of such
training shall result in recovery of any payments made by the
Department for services rendered by a non-certified driver or
employee attendant. Medi-car and service car providers must
maintain legible documentation in their records of the driver
and, as applicable, employee attendant that actually
transported the patient. Providers must recertify all drivers
and employee attendants every 3 years.
    Notwithstanding the requirements above, any public
transportation provider of medi-car and service car
transportation that receives federal funding under 49 U.S.C.
5307 and 5311 need not certify its drivers and employee
attendants under this Section, since safety training is already
federally mandated.
    (f) With respect to any policy or program administered by
the Department or its agent regarding approval of non-emergency
medical transportation by ground ambulance service providers,
including, but not limited to, the Non-Emergency
Transportation Services Prior Approval Program (NETSPAP), the
Department shall establish by rule a process by which ground
ambulance service providers of non-emergency medical
transportation may appeal any decision by the Department or its
agent for which no denial was received prior to the time of
transport that either (i) denies a request for approval for
payment of non-emergency transportation by means of ground
ambulance service or (ii) grants a request for approval of
non-emergency transportation by means of ground ambulance
service at a level of service that entitles the ground
ambulance service provider to a lower level of compensation
from the Department than the ground ambulance service provider
would have received as compensation for the level of service
requested. The rule shall be filed by December 15, 2012
established within 12 months after the effective date of this
amendatory Act of the 97th General Assembly and shall provide
that, for any decision rendered by the Department or its agent
on or after the date the rule takes effect, the ground
ambulance service provider shall have 60 days from the date the
decision is received to file an appeal. The rule established by
the Department shall be, insofar as is practical, consistent
with the Illinois Administrative Procedure Act. The Director's
decision on an appeal under this Section shall be a final
administrative decision subject to review under the
Administrative Review Law.
    (g) Whenever a patient covered by a medical assistance
program under this Code or by another medical program
administered by the Department is being discharged from a
facility, a physician discharge order as described in this
Section shall be required for each patient whose discharge
requires medically supervised ground ambulance services.
Facilities shall develop procedures for a physician with
medical staff privileges to provide a written and signed
physician discharge order. The physician discharge order shall
specify the level of ground ambulance services needed and
complete a medical certification establishing the criteria for
approval of non-emergency ambulance transportation, as
published by the Department of Healthcare and Family Services,
that is met by the patient. This order and the medical
certification shall be completed prior to ordering an ambulance
service and prior to patient discharge.
    Pursuant to subsection (E) of Section 12-4.25 of this Code,
the Department is entitled to recover overpayments paid to a
provider or vendor, including, but not limited to, from the
discharging physician, the discharging facility, and the
ground ambulance service provider, in instances where a
non-emergency ground ambulance service is rendered as the
result of improper or false certification.
    (h) On and after July 1, 2012, the Department shall reduce
any rate of reimbursement for services or other payments or
alter any methodologies authorized by this Code to reduce any
rate of reimbursement for services or other payments in
accordance with Section 5-5e.
(Source: P.A. 97-584, eff. 8-26-11.)
 
    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
    Sec. 5-5. Medical services. The Illinois Department, by
rule, shall determine the quantity and quality of and the rate
of reimbursement for the medical assistance for which payment
will be authorized, and the medical services to be provided,
which may include all or part of the following: (1) inpatient
hospital services; (2) outpatient hospital services; (3) other
laboratory and X-ray services; (4) skilled nursing home
services; (5) physicians' services whether furnished in the
office, the patient's home, a hospital, a skilled nursing home,
or elsewhere; (6) medical care, or any other type of remedial
care furnished by licensed practitioners; (7) home health care
services; (8) private duty nursing service; (9) clinic
services; (10) dental services, including prevention and
treatment of periodontal disease and dental caries disease for
pregnant women, provided by an individual licensed to practice
dentistry or dental surgery; for purposes of this item (10),
"dental services" means diagnostic, preventive, or corrective
procedures provided by or under the supervision of a dentist in
the practice of his or her profession; (11) physical therapy
and related services; (12) prescribed drugs, dentures, and
prosthetic devices; and eyeglasses prescribed by a physician
skilled in the diseases of the eye, or by an optometrist,
whichever the person may select; (13) other diagnostic,
screening, preventive, and rehabilitative services, for
children and adults; (14) transportation and such other
expenses as may be necessary; (15) medical treatment of sexual
assault survivors, as defined in Section 1a of the Sexual
Assault Survivors Emergency Treatment Act, for injuries
sustained as a result of the sexual assault, including
examinations and laboratory tests to discover evidence which
may be used in criminal proceedings arising from the sexual
assault; (16) the diagnosis and treatment of sickle cell
anemia; and (17) any other medical care, and any other type of
remedial care recognized under the laws of this State, but not
including abortions, or induced miscarriages or premature
births, unless, in the opinion of a physician, such procedures
are necessary for the preservation of the life of the woman
seeking such treatment, or except an induced premature birth
intended to produce a live viable child and such procedure is
necessary for the health of the mother or her unborn child. The
Illinois Department, by rule, shall prohibit any physician from
providing medical assistance to anyone eligible therefor under
this Code where such physician has been found guilty of
performing an abortion procedure in a wilful and wanton manner
upon a woman who was not pregnant at the time such abortion
procedure was performed. The term "any other type of remedial
care" shall include nursing care and nursing home service for
persons who rely on treatment by spiritual means alone through
prayer for healing.
    Notwithstanding any other provision of this Section, a
comprehensive tobacco use cessation program that includes
purchasing prescription drugs or prescription medical devices
approved by the Food and Drug Administration shall be covered
under the medical assistance program under this Article for
persons who are otherwise eligible for assistance under this
Article.
    Notwithstanding any other provision of this Code, the
Illinois Department may not require, as a condition of payment
for any laboratory test authorized under this Article, that a
physician's handwritten signature appear on the laboratory
test order form. The Illinois Department may, however, impose
other appropriate requirements regarding laboratory test order
documentation.
    On and after July 1, 2012, the The Department of Healthcare
and Family Services may shall provide the following services to
persons eligible for assistance under this Article who are
participating in education, training or employment programs
operated by the Department of Human Services as successor to
the Department of Public Aid:
        (1) dental services provided by or under the
    supervision of a dentist; and
        (2) eyeglasses prescribed by a physician skilled in the
    diseases of the eye, or by an optometrist, whichever the
    person may select.
    Notwithstanding any other provision of this Code and
subject to federal approval, the Department may adopt rules to
allow a dentist who is volunteering his or her service at no
cost to render dental services through an enrolled
not-for-profit health clinic without the dentist personally
enrolling as a participating provider in the medical assistance
program. A not-for-profit health clinic shall include a public
health clinic or Federally Qualified Health Center or other
enrolled provider, as determined by the Department, through
which dental services covered under this Section are performed.
The Department shall establish a process for payment of claims
for reimbursement for covered dental services rendered under
this provision.
    The Illinois Department, by rule, may distinguish and
classify the medical services to be provided only in accordance
with the classes of persons designated in Section 5-2.
    The Department of Healthcare and Family Services must
provide coverage and reimbursement for amino acid-based
elemental formulas, regardless of delivery method, for the
diagnosis and treatment of (i) eosinophilic disorders and (ii)
short bowel syndrome when the prescribing physician has issued
a written order stating that the amino acid-based elemental
formula is medically necessary.
    The Illinois Department shall authorize the provision of,
and shall authorize payment for, screening by low-dose
mammography for the presence of occult breast cancer for women
35 years of age or older who are eligible for medical
assistance under this Article, as follows:
        (A) A baseline mammogram for women 35 to 39 years of
    age.
        (B) An annual mammogram for women 40 years of age or
    older.
        (C) A mammogram at the age and intervals considered
    medically necessary by the woman's health care provider for
    women under 40 years of age and having a family history of
    breast cancer, prior personal history of breast cancer,
    positive genetic testing, or other risk factors.
        (D) A comprehensive ultrasound screening of an entire
    breast or breasts if a mammogram demonstrates
    heterogeneous or dense breast tissue, when medically
    necessary as determined by a physician licensed to practice
    medicine in all of its branches.
    All screenings shall include a physical breast exam,
instruction on self-examination and information regarding the
frequency of self-examination and its value as a preventative
tool. For purposes of this Section, "low-dose mammography"
means the x-ray examination of the breast using equipment
dedicated specifically for mammography, including the x-ray
tube, filter, compression device, and image receptor, with an
average radiation exposure delivery of less than one rad per
breast for 2 views of an average size breast. The term also
includes digital mammography.
    On and after January 1, 2012, providers participating in a
quality improvement program approved by the Department shall be
reimbursed for screening and diagnostic mammography at the same
rate as the Medicare program's rates, including the increased
reimbursement for digital mammography.
    The Department shall convene an expert panel including
representatives of hospitals, free-standing mammography
facilities, and doctors, including radiologists, to establish
quality standards.
    Subject to federal approval, the Department shall
establish a rate methodology for mammography at federally
qualified health centers and other encounter-rate clinics.
These clinics or centers may also collaborate with other
hospital-based mammography facilities.
    The Department shall establish a methodology to remind
women who are age-appropriate for screening mammography, but
who have not received a mammogram within the previous 18
months, of the importance and benefit of screening mammography.
    The Department shall establish a performance goal for
primary care providers with respect to their female patients
over age 40 receiving an annual mammogram. This performance
goal shall be used to provide additional reimbursement in the
form of a quality performance bonus to primary care providers
who meet that goal.
    The Department shall devise a means of case-managing or
patient navigation for beneficiaries diagnosed with breast
cancer. This program shall initially operate as a pilot program
in areas of the State with the highest incidence of mortality
related to breast cancer. At least one pilot program site shall
be in the metropolitan Chicago area and at least one site shall
be outside the metropolitan Chicago area. An evaluation of the
pilot program shall be carried out measuring health outcomes
and cost of care for those served by the pilot program compared
to similarly situated patients who are not served by the pilot
program.
    Any medical or health care provider shall immediately
recommend, to any pregnant woman who is being provided prenatal
services and is suspected of drug abuse or is addicted as
defined in the Alcoholism and Other Drug Abuse and Dependency
Act, referral to a local substance abuse treatment provider
licensed by the Department of Human Services or to a licensed
hospital which provides substance abuse treatment services.
The Department of Healthcare and Family Services shall assure
coverage for the cost of treatment of the drug abuse or
addiction for pregnant recipients in accordance with the
Illinois Medicaid Program in conjunction with the Department of
Human Services.
    All medical providers providing medical assistance to
pregnant women under this Code shall receive information from
the Department on the availability of services under the Drug
Free Families with a Future or any comparable program providing
case management services for addicted women, including
information on appropriate referrals for other social services
that may be needed by addicted women in addition to treatment
for addiction.
    The Illinois Department, in cooperation with the
Departments of Human Services (as successor to the Department
of Alcoholism and Substance Abuse) and Public Health, through a
public awareness campaign, may provide information concerning
treatment for alcoholism and drug abuse and addiction, prenatal
health care, and other pertinent programs directed at reducing
the number of drug-affected infants born to recipients of
medical assistance.
    Neither the Department of Healthcare and Family Services
nor the Department of Human Services shall sanction the
recipient solely on the basis of her substance abuse.
    The Illinois Department shall establish such regulations
governing the dispensing of health services under this Article
as it shall deem appropriate. The Department should seek the
advice of formal professional advisory committees appointed by
the Director of the Illinois Department for the purpose of
providing regular advice on policy and administrative matters,
information dissemination and educational activities for
medical and health care providers, and consistency in
procedures to the Illinois Department.
    Notwithstanding any other provision of law, a health care
provider under the medical assistance program may elect, in
lieu of receiving direct payment for services provided under
that program, to participate in the State Employees Deferred
Compensation Plan adopted under Article 24 of the Illinois
Pension Code. A health care provider who elects to participate
in the plan does not have a cause of action against the State
for any damages allegedly suffered by the provider as a result
of any delay by the State in crediting the amount of any
contribution to the provider's plan account.
    The Illinois Department may develop and contract with
Partnerships of medical providers to arrange medical services
for persons eligible under Section 5-2 of this Code.
Implementation of this Section may be by demonstration projects
in certain geographic areas. The Partnership shall be
represented by a sponsor organization. The Department, by rule,
shall develop qualifications for sponsors of Partnerships.
Nothing in this Section shall be construed to require that the
sponsor organization be a medical organization.
    The sponsor must negotiate formal written contracts with
medical providers for physician services, inpatient and
outpatient hospital care, home health services, treatment for
alcoholism and substance abuse, and other services determined
necessary by the Illinois Department by rule for delivery by
Partnerships. Physician services must include prenatal and
obstetrical care. The Illinois Department shall reimburse
medical services delivered by Partnership providers to clients
in target areas according to provisions of this Article and the
Illinois Health Finance Reform Act, except that:
        (1) Physicians participating in a Partnership and
    providing certain services, which shall be determined by
    the Illinois Department, to persons in areas covered by the
    Partnership may receive an additional surcharge for such
    services.
        (2) The Department may elect to consider and negotiate
    financial incentives to encourage the development of
    Partnerships and the efficient delivery of medical care.
        (3) Persons receiving medical services through
    Partnerships may receive medical and case management
    services above the level usually offered through the
    medical assistance program.
    Medical providers shall be required to meet certain
qualifications to participate in Partnerships to ensure the
delivery of high quality medical services. These
qualifications shall be determined by rule of the Illinois
Department and may be higher than qualifications for
participation in the medical assistance program. Partnership
sponsors may prescribe reasonable additional qualifications
for participation by medical providers, only with the prior
written approval of the Illinois Department.
    Nothing in this Section shall limit the free choice of
practitioners, hospitals, and other providers of medical
services by clients. In order to ensure patient freedom of
choice, the Illinois Department shall immediately promulgate
all rules and take all other necessary actions so that provided
services may be accessed from therapeutically certified
optometrists to the full extent of the Illinois Optometric
Practice Act of 1987 without discriminating between service
providers.
    The Department shall apply for a waiver from the United
States Health Care Financing Administration to allow for the
implementation of Partnerships under this Section.
    The Illinois Department shall require health care
providers to maintain records that document the medical care
and services provided to recipients of Medical Assistance under
this Article. Such records must be retained for a period of not
less than 6 years from the date of service or as provided by
applicable State law, whichever period is longer, except that
if an audit is initiated within the required retention period
then the records must be retained until the audit is completed
and every exception is resolved. The Illinois Department shall
require health care providers to make available, when
authorized by the patient, in writing, the medical records in a
timely fashion to other health care providers who are treating
or serving persons eligible for Medical Assistance under this
Article. All dispensers of medical services shall be required
to maintain and retain business and professional records
sufficient to fully and accurately document the nature, scope,
details and receipt of the health care provided to persons
eligible for medical assistance under this Code, in accordance
with regulations promulgated by the Illinois Department. The
rules and regulations shall require that proof of the receipt
of prescription drugs, dentures, prosthetic devices and
eyeglasses by eligible persons under this Section accompany
each claim for reimbursement submitted by the dispenser of such
medical services. No such claims for reimbursement shall be
approved for payment by the Illinois Department without such
proof of receipt, unless the Illinois Department shall have put
into effect and shall be operating a system of post-payment
audit and review which shall, on a sampling basis, be deemed
adequate by the Illinois Department to assure that such drugs,
dentures, prosthetic devices and eyeglasses for which payment
is being made are actually being received by eligible
recipients. Within 90 days after the effective date of this
amendatory Act of 1984, the Illinois Department shall establish
a current list of acquisition costs for all prosthetic devices
and any other items recognized as medical equipment and
supplies reimbursable under this Article and shall update such
list on a quarterly basis, except that the acquisition costs of
all prescription drugs shall be updated no less frequently than
every 30 days as required by Section 5-5.12.
    The rules and regulations of the Illinois Department shall
require that a written statement including the required opinion
of a physician shall accompany any claim for reimbursement for
abortions, or induced miscarriages or premature births. This
statement shall indicate what procedures were used in providing
such medical services.
    The Illinois Department shall require all dispensers of
medical services, other than an individual practitioner or
group of practitioners, desiring to participate in the Medical
Assistance program established under this Article to disclose
all financial, beneficial, ownership, equity, surety or other
interests in any and all firms, corporations, partnerships,
associations, business enterprises, joint ventures, agencies,
institutions or other legal entities providing any form of
health care services in this State under this Article.
    The Illinois Department may require that all dispensers of
medical services desiring to participate in the medical
assistance program established under this Article disclose,
under such terms and conditions as the Illinois Department may
by rule establish, all inquiries from clients and attorneys
regarding medical bills paid by the Illinois Department, which
inquiries could indicate potential existence of claims or liens
for the Illinois Department.
    Enrollment of a vendor that provides non-emergency medical
transportation, defined by the Department by rule, shall be
subject to a provisional period and shall be conditional for
one year 180 days. During the period of conditional enrollment
that time, the Department of Healthcare and Family Services may
terminate the vendor's eligibility to participate in, or may
disenroll the vendor from, the medical assistance program
without cause. Unless otherwise specified, such That
termination of eligibility or disenrollment is not subject to
the Department's hearing process. However, a disenrolled
vendor may reapply without penalty.
    The Department has the discretion to limit the conditional
enrollment period for vendors based upon category of risk of
the vendor.
    Prior to enrollment and during the conditional enrollment
period in the medical assistance program, all vendors shall be
subject to enhanced oversight, screening, and review based on
the risk of fraud, waste, and abuse that is posed by the
category of risk of the vendor. The Illinois Department shall
establish the procedures for oversight, screening, and review,
which may include, but need not be limited to: criminal and
financial background checks; fingerprinting; license,
certification, and authorization verifications; unscheduled or
unannounced site visits; database checks; prepayment audit
reviews; audits; payment caps; payment suspensions; and other
screening as required by federal or State law.
    The Department shall define or specify the following: (i)
by provider notice, the "category of risk of the vendor" for
each type of vendor, which shall take into account the level of
screening applicable to a particular category of vendor under
federal law and regulations; (ii) by rule or provider notice,
the maximum length of the conditional enrollment period for
each category of risk of the vendor; and (iii) by rule, the
hearing rights, if any, afforded to a vendor in each category
of risk of the vendor that is terminated or disenrolled during
the conditional enrollment period.
    To be eligible for payment consideration, a vendor's
payment claim or bill, either as an initial claim or as a
resubmitted claim following prior rejection, must be received
by the Illinois Department, or its fiscal intermediary, no
later than 180 days after the latest date on the claim on which
medical goods or services were provided, with the following
exceptions:
        (1) In the case of a provider whose enrollment is in
    process by the Illinois Department, the 180-day period
    shall not begin until the date on the written notice from
    the Illinois Department that the provider enrollment is
    complete.
        (2) In the case of errors attributable to the Illinois
    Department or any of its claims processing intermediaries
    which result in an inability to receive, process, or
    adjudicate a claim, the 180-day period shall not begin
    until the provider has been notified of the error.
        (3) In the case of a provider for whom the Illinois
    Department initiates the monthly billing process.
    For claims for services rendered during a period for which
a recipient received retroactive eligibility, claims must be
filed within 180 days after the Department determines the
applicant is eligible. For claims for which the Illinois
Department is not the primary payer, claims must be submitted
to the Illinois Department within 180 days after the final
adjudication by the primary payer.
    In the case of long term care facilities, admission
documents shall be submitted within 30 days of an admission to
the facility through the Medical Electronic Data Interchange
(MEDI) or the Recipient Eligibility Verification (REV) System,
or shall be submitted directly to the Department of Human
Services using required admission forms. Confirmation numbers
assigned to an accepted transaction shall be retained by a
facility to verify timely submittal. Once an admission
transaction has been completed, all resubmitted claims
following prior rejection are subject to receipt no later than
180 days after the admission transaction has been completed.
    Claims that are not submitted and received in compliance
with the foregoing requirements shall not be eligible for
payment under the medical assistance program, and the State
shall have no liability for payment of those claims.
    To the extent consistent with applicable information and
privacy, security, and disclosure laws, State and federal
agencies and departments shall provide the Illinois Department
access to confidential and other information and data necessary
to perform eligibility and payment verifications and other
Illinois Department functions. This includes, but is not
limited to: information pertaining to licensure;
certification; earnings; immigration status; citizenship; wage
reporting; unearned and earned income; pension income;
employment; supplemental security income; social security
numbers; National Provider Identifier (NPI) numbers; the
National Practitioner Data Bank (NPDB); program and agency
exclusions; taxpayer identification numbers; tax delinquency;
corporate information; and death records.
    The Illinois Department shall enter into agreements with
State agencies and departments, and is authorized to enter into
agreements with federal agencies and departments, under which
such agencies and departments shall share data necessary for
medical assistance program integrity functions and oversight.
The Illinois Department shall develop, in cooperation with
other State departments and agencies, and in compliance with
applicable federal laws and regulations, appropriate and
effective methods to share such data. At a minimum, and to the
extent necessary to provide data sharing, the Illinois
Department shall enter into agreements with State agencies and
departments, and is authorized to enter into agreements with
federal agencies and departments, including but not limited to:
the Secretary of State; the Department of Revenue; the
Department of Public Health; the Department of Human Services;
and the Department of Financial and Professional Regulation.
    Beginning in fiscal year 2013, the Illinois Department
shall set forth a request for information to identify the
benefits of a pre-payment, post-adjudication, and post-edit
claims system with the goals of streamlining claims processing
and provider reimbursement, reducing the number of pending or
rejected claims, and helping to ensure a more transparent
adjudication process through the utilization of: (i) provider
data verification and provider screening technology; and (ii)
clinical code editing; and (iii) pre-pay, pre- or
post-adjudicated predictive modeling with an integrated case
management system with link analysis. Such a request for
information shall not be considered as a request for proposal
or as an obligation on the part of the Illinois Department to
take any action or acquire any products or services.
    The Illinois Department shall establish policies,
procedures, standards and criteria by rule for the acquisition,
repair and replacement of orthotic and prosthetic devices and
durable medical equipment. Such rules shall provide, but not be
limited to, the following services: (1) immediate repair or
replacement of such devices by recipients without medical
authorization; and (2) rental, lease, purchase or
lease-purchase of durable medical equipment in a
cost-effective manner, taking into consideration the
recipient's medical prognosis, the extent of the recipient's
needs, and the requirements and costs for maintaining such
equipment. Subject to prior approval, such Such rules shall
enable a recipient to temporarily acquire and use alternative
or substitute devices or equipment pending repairs or
replacements of any device or equipment previously authorized
for such recipient by the Department.
    The Department shall execute, relative to the nursing home
prescreening project, written inter-agency agreements with the
Department of Human Services and the Department on Aging, to
effect the following: (i) intake procedures and common
eligibility criteria for those persons who are receiving
non-institutional services; and (ii) the establishment and
development of non-institutional services in areas of the State
where they are not currently available or are undeveloped; and
(iii) notwithstanding any other provision of law, subject to
federal approval, on and after July 1, 2012, an increase in the
determination of need (DON) scores from 29 to 37 for applicants
for institutional and home and community-based long term care;
if and only if federal approval is not granted, the Department
may, in conjunction with other affected agencies, implement
utilization controls or changes in benefit packages to
effectuate a similar savings amount for this population; and
(iv) no later than July 1, 2013, minimum level of care
eligibility criteria for institutional and home and
community-based long term care. In order to select the minimum
level of care eligibility criteria, the Governor shall
establish a workgroup that includes affected agency
representatives and stakeholders representing the
institutional and home and community-based long term care
interests. This Section shall not restrict the Department from
implementing lower level of care eligibility criteria for
community-based services in circumstances where federal
approval has been granted.
    The Illinois Department shall develop and operate, in
cooperation with other State Departments and agencies and in
compliance with applicable federal laws and regulations,
appropriate and effective systems of health care evaluation and
programs for monitoring of utilization of health care services
and facilities, as it affects persons eligible for medical
assistance under this Code.
    The Illinois Department shall report annually to the
General Assembly, no later than the second Friday in April of
1979 and each year thereafter, in regard to:
        (a) actual statistics and trends in utilization of
    medical services by public aid recipients;
        (b) actual statistics and trends in the provision of
    the various medical services by medical vendors;
        (c) current rate structures and proposed changes in
    those rate structures for the various medical vendors; and
        (d) efforts at utilization review and control by the
    Illinois Department.
    The period covered by each report shall be the 3 years
ending on the June 30 prior to the report. The report shall
include suggested legislation for consideration by the General
Assembly. The filing of one copy of the report with the
Speaker, one copy with the Minority Leader and one copy with
the Clerk of the House of Representatives, one copy with the
President, one copy with the Minority Leader and one copy with
the Secretary of the Senate, one copy with the Legislative
Research Unit, and such additional copies with the State
Government Report Distribution Center for the General Assembly
as is required under paragraph (t) of Section 7 of the State
Library Act shall be deemed sufficient to comply with this
Section.
    Rulemaking authority to implement Public Act 95-1045, if
any, is conditioned on the rules being adopted in accordance
with all provisions of the Illinois Administrative Procedure
Act and all rules and procedures of the Joint Committee on
Administrative Rules; any purported rule not so adopted, for
whatever reason, is unauthorized.
    On and after July 1, 2012, the Department shall reduce any
rate of reimbursement for services or other payments or alter
any methodologies authorized by this Code to reduce any rate of
reimbursement for services or other payments in accordance with
Section 5-5e.
(Source: P.A. 96-156, eff. 1-1-10; 96-806, eff. 7-1-10; 96-926,
eff. 1-1-11; 96-1000, eff. 7-2-10; 97-48, eff. 6-28-11; 97-638,
eff. 1-1-12.)
 
    (305 ILCS 5/5-5.02)  (from Ch. 23, par. 5-5.02)
    Sec. 5-5.02. Hospital reimbursements.
    (a) Reimbursement to Hospitals; July 1, 1992 through
September 30, 1992. Notwithstanding any other provisions of
this Code or the Illinois Department's Rules promulgated under
the Illinois Administrative Procedure Act, reimbursement to
hospitals for services provided during the period July 1, 1992
through September 30, 1992, shall be as follows:
        (1) For inpatient hospital services rendered, or if
    applicable, for inpatient hospital discharges occurring,
    on or after July 1, 1992 and on or before September 30,
    1992, the Illinois Department shall reimburse hospitals
    for inpatient services under the reimbursement
    methodologies in effect for each hospital, and at the
    inpatient payment rate calculated for each hospital, as of
    June 30, 1992. For purposes of this paragraph,
    "reimbursement methodologies" means all reimbursement
    methodologies that pertain to the provision of inpatient
    hospital services, including, but not limited to, any
    adjustments for disproportionate share, targeted access,
    critical care access and uncompensated care, as defined by
    the Illinois Department on June 30, 1992.
        (2) For the purpose of calculating the inpatient
    payment rate for each hospital eligible to receive
    quarterly adjustment payments for targeted access and
    critical care, as defined by the Illinois Department on
    June 30, 1992, the adjustment payment for the period July
    1, 1992 through September 30, 1992, shall be 25% of the
    annual adjustment payments calculated for each eligible
    hospital, as of June 30, 1992. The Illinois Department
    shall determine by rule the adjustment payments for
    targeted access and critical care beginning October 1,
    1992.
        (3) For the purpose of calculating the inpatient
    payment rate for each hospital eligible to receive
    quarterly adjustment payments for uncompensated care, as
    defined by the Illinois Department on June 30, 1992, the
    adjustment payment for the period August 1, 1992 through
    September 30, 1992, shall be one-sixth of the total
    uncompensated care adjustment payments calculated for each
    eligible hospital for the uncompensated care rate year, as
    defined by the Illinois Department, ending on July 31,
    1992. The Illinois Department shall determine by rule the
    adjustment payments for uncompensated care beginning
    October 1, 1992.
    (b) Inpatient payments. For inpatient services provided on
or after October 1, 1993, in addition to rates paid for
hospital inpatient services pursuant to the Illinois Health
Finance Reform Act, as now or hereafter amended, or the
Illinois Department's prospective reimbursement methodology,
or any other methodology used by the Illinois Department for
inpatient services, the Illinois Department shall make
adjustment payments, in an amount calculated pursuant to the
methodology described in paragraph (c) of this Section, to
hospitals that the Illinois Department determines satisfy any
one of the following requirements:
        (1) Hospitals that are described in Section 1923 of the
    federal Social Security Act, as now or hereafter amended;
    or
        (2) Illinois hospitals that have a Medicaid inpatient
    utilization rate which is at least one-half a standard
    deviation above the mean Medicaid inpatient utilization
    rate for all hospitals in Illinois receiving Medicaid
    payments from the Illinois Department; or
        (3) Illinois hospitals that on July 1, 1991 had a
    Medicaid inpatient utilization rate, as defined in
    paragraph (h) of this Section, that was at least the mean
    Medicaid inpatient utilization rate for all hospitals in
    Illinois receiving Medicaid payments from the Illinois
    Department and which were located in a planning area with
    one-third or fewer excess beds as determined by the Health
    Facilities and Services Review Board, and that, as of June
    30, 1992, were located in a federally designated Health
    Manpower Shortage Area; or
        (4) Illinois hospitals that:
            (A) have a Medicaid inpatient utilization rate
        that is at least equal to the mean Medicaid inpatient
        utilization rate for all hospitals in Illinois
        receiving Medicaid payments from the Department; and
            (B) also have a Medicaid obstetrical inpatient
        utilization rate that is at least one standard
        deviation above the mean Medicaid obstetrical
        inpatient utilization rate for all hospitals in
        Illinois receiving Medicaid payments from the
        Department for obstetrical services; or
        (5) Any children's hospital, which means a hospital
    devoted exclusively to caring for children. A hospital
    which includes a facility devoted exclusively to caring for
    children shall be considered a children's hospital to the
    degree that the hospital's Medicaid care is provided to
    children if either (i) the facility devoted exclusively to
    caring for children is separately licensed as a hospital by
    a municipality prior to September 30, 1998 or (ii) the
    hospital has been designated by the State as a Level III
    perinatal care facility, has a Medicaid Inpatient
    Utilization rate greater than 55% for the rate year 2003
    disproportionate share determination, and has more than
    10,000 qualified children days as defined by the Department
    in rulemaking.
    (c) Inpatient adjustment payments. The adjustment payments
required by paragraph (b) shall be calculated based upon the
hospital's Medicaid inpatient utilization rate as follows:
        (1) hospitals with a Medicaid inpatient utilization
    rate below the mean shall receive a per day adjustment
    payment equal to $25;
        (2) hospitals with a Medicaid inpatient utilization
    rate that is equal to or greater than the mean Medicaid
    inpatient utilization rate but less than one standard
    deviation above the mean Medicaid inpatient utilization
    rate shall receive a per day adjustment payment equal to
    the sum of $25 plus $1 for each one percent that the
    hospital's Medicaid inpatient utilization rate exceeds the
    mean Medicaid inpatient utilization rate;
        (3) hospitals with a Medicaid inpatient utilization
    rate that is equal to or greater than one standard
    deviation above the mean Medicaid inpatient utilization
    rate but less than 1.5 standard deviations above the mean
    Medicaid inpatient utilization rate shall receive a per day
    adjustment payment equal to the sum of $40 plus $7 for each
    one percent that the hospital's Medicaid inpatient
    utilization rate exceeds one standard deviation above the
    mean Medicaid inpatient utilization rate; and
        (4) hospitals with a Medicaid inpatient utilization
    rate that is equal to or greater than 1.5 standard
    deviations above the mean Medicaid inpatient utilization
    rate shall receive a per day adjustment payment equal to
    the sum of $90 plus $2 for each one percent that the
    hospital's Medicaid inpatient utilization rate exceeds 1.5
    standard deviations above the mean Medicaid inpatient
    utilization rate.
    (d) Supplemental adjustment payments. In addition to the
adjustment payments described in paragraph (c), hospitals as
defined in clauses (1) through (5) of paragraph (b), excluding
county hospitals (as defined in subsection (c) of Section 15-1
of this Code) and a hospital organized under the University of
Illinois Hospital Act, shall be paid supplemental inpatient
adjustment payments of $60 per day. For purposes of Title XIX
of the federal Social Security Act, these supplemental
adjustment payments shall not be classified as adjustment
payments to disproportionate share hospitals.
    (e) The inpatient adjustment payments described in
paragraphs (c) and (d) shall be increased on October 1, 1993
and annually thereafter by a percentage equal to the lesser of
(i) the increase in the DRI hospital cost index for the most
recent 12 month period for which data are available, or (ii)
the percentage increase in the statewide average hospital
payment rate over the previous year's statewide average
hospital payment rate. The sum of the inpatient adjustment
payments under paragraphs (c) and (d) to a hospital, other than
a county hospital (as defined in subsection (c) of Section 15-1
of this Code) or a hospital organized under the University of
Illinois Hospital Act, however, shall not exceed $275 per day;
that limit shall be increased on October 1, 1993 and annually
thereafter by a percentage equal to the lesser of (i) the
increase in the DRI hospital cost index for the most recent
12-month period for which data are available or (ii) the
percentage increase in the statewide average hospital payment
rate over the previous year's statewide average hospital
payment rate.
    (f) Children's hospital inpatient adjustment payments. For
children's hospitals, as defined in clause (5) of paragraph
(b), the adjustment payments required pursuant to paragraphs
(c) and (d) shall be multiplied by 2.0.
    (g) County hospital inpatient adjustment payments. For
county hospitals, as defined in subsection (c) of Section 15-1
of this Code, there shall be an adjustment payment as
determined by rules issued by the Illinois Department.
    (h) For the purposes of this Section the following terms
shall be defined as follows:
        (1) "Medicaid inpatient utilization rate" means a
    fraction, the numerator of which is the number of a
    hospital's inpatient days provided in a given 12-month
    period to patients who, for such days, were eligible for
    Medicaid under Title XIX of the federal Social Security
    Act, and the denominator of which is the total number of
    the hospital's inpatient days in that same period.
        (2) "Mean Medicaid inpatient utilization rate" means
    the total number of Medicaid inpatient days provided by all
    Illinois Medicaid-participating hospitals divided by the
    total number of inpatient days provided by those same
    hospitals.
        (3) "Medicaid obstetrical inpatient utilization rate"
    means the ratio of Medicaid obstetrical inpatient days to
    total Medicaid inpatient days for all Illinois hospitals
    receiving Medicaid payments from the Illinois Department.
    (i) Inpatient adjustment payment limit. In order to meet
the limits of Public Law 102-234 and Public Law 103-66, the
Illinois Department shall by rule adjust disproportionate
share adjustment payments.
    (j) University of Illinois Hospital inpatient adjustment
payments. For hospitals organized under the University of
Illinois Hospital Act, there shall be an adjustment payment as
determined by rules adopted by the Illinois Department.
    (k) The Illinois Department may by rule establish criteria
for and develop methodologies for adjustment payments to
hospitals participating under this Article.
    (l) On and after July 1, 2012, the Department shall reduce
any rate of reimbursement for services or other payments or
alter any methodologies authorized by this Code to reduce any
rate of reimbursement for services or other payments in
accordance with Section 5-5e.
(Source: P.A. 96-31, eff. 6-30-09.)
 
    (305 ILCS 5/5-5.05)
    Sec. 5-5.05. Hospitals; psychiatric services.
    (a) On and after July 1, 2008, the inpatient, per diem rate
to be paid to a hospital for inpatient psychiatric services
shall be $363.77.
    (b) For purposes of this Section, "hospital" means the
following:
        (1) Advocate Christ Hospital, Oak Lawn, Illinois.
        (2) Barnes-Jewish Hospital, St. Louis, Missouri.
        (3) BroMenn Healthcare, Bloomington, Illinois.
        (4) Jackson Park Hospital, Chicago, Illinois.
        (5) Katherine Shaw Bethea Hospital, Dixon, Illinois.
        (6) Lawrence County Memorial Hospital, Lawrenceville,
    Illinois.
        (7) Advocate Lutheran General Hospital, Park Ridge,
    Illinois.
        (8) Mercy Hospital and Medical Center, Chicago,
    Illinois.
        (9) Methodist Medical Center of Illinois, Peoria,
    Illinois.
        (10) Provena United Samaritans Medical Center,
    Danville, Illinois.
        (11) Rockford Memorial Hospital, Rockford, Illinois.
        (12) Sarah Bush Lincoln Health Center, Mattoon,
    Illinois.
        (13) Provena Covenant Medical Center, Urbana,
    Illinois.
        (14) Rush-Presbyterian-St. Luke's Medical Center,
    Chicago, Illinois.
        (15) Mt. Sinai Hospital, Chicago, Illinois.
        (16) Gateway Regional Medical Center, Granite City,
    Illinois.
        (17) St. Mary of Nazareth Hospital, Chicago, Illinois.
        (18) Provena St. Mary's Hospital, Kankakee, Illinois.
        (19) St. Mary's Hospital, Decatur, Illinois.
        (20) Memorial Hospital, Belleville, Illinois.
        (21) Swedish Covenant Hospital, Chicago, Illinois.
        (22) Trinity Medical Center, Rock Island, Illinois.
        (23) St. Elizabeth Hospital, Chicago, Illinois.
        (24) Richland Memorial Hospital, Olney, Illinois.
        (25) St. Elizabeth's Hospital, Belleville, Illinois.
        (26) Samaritan Health System, Clinton, Iowa.
        (27) St. John's Hospital, Springfield, Illinois.
        (28) St. Mary's Hospital, Centralia, Illinois.
        (29) Loretto Hospital, Chicago, Illinois.
        (30) Kenneth Hall Regional Hospital, East St. Louis,
    Illinois.
        (31) Hinsdale Hospital, Hinsdale, Illinois.
        (32) Pekin Hospital, Pekin, Illinois.
        (33) University of Chicago Medical Center, Chicago,
    Illinois.
        (34) St. Anthony's Health Center, Alton, Illinois.
        (35) OSF St. Francis Medical Center, Peoria, Illinois.
        (36) Memorial Medical Center, Springfield, Illinois.
        (37) A hospital with a distinct part unit for
    psychiatric services that begins operating on or after July
    1, 2008.
    For purposes of this Section, "inpatient psychiatric
services" means those services provided to patients who are in
need of short-term acute inpatient hospitalization for active
treatment of an emotional or mental disorder.
    (c) No rules shall be promulgated to implement this
Section. For purposes of this Section, "rules" is given the
meaning contained in Section 1-70 of the Illinois
Administrative Procedure Act.
    (d) This Section shall not be in effect during any period
of time that the State has in place a fully operational
hospital assessment plan that has been approved by the Centers
for Medicare and Medicaid Services of the U.S. Department of
Health and Human Services.
    (e) On and after July 1, 2012, the Department shall reduce
any rate of reimbursement for services or other payments or
alter any methodologies authorized by this Code to reduce any
rate of reimbursement for services or other payments in
accordance with Section 5-5e.
(Source: P.A. 95-1013, eff. 12-15-08.)
 
    (305 ILCS 5/5-5.2)  (from Ch. 23, par. 5-5.2)
    Sec. 5-5.2. Payment.
    (a) All nursing facilities that are grouped pursuant to
Section 5-5.1 of this Act shall receive the same rate of
payment for similar services.
    (b) It shall be a matter of State policy that the Illinois
Department shall utilize a uniform billing cycle throughout the
State for the long-term care providers.
    (c) Notwithstanding any other provisions of this Code,
beginning July 1, 2012 the methodologies for reimbursement of
nursing facility services as provided under this Article shall
no longer be applicable for bills payable for nursing services
rendered on or after a new reimbursement system based on the
Resource Utilization Groups (RUGs) has been fully
operationalized, which shall take effect for services provided
on or after January 1, 2014. State fiscal years 2012 and
thereafter. The Department of Healthcare and Family Services
shall, effective July 1, 2012, implement an evidence-based
payment methodology for the reimbursement of nursing facility
services. The methodology shall continue to take into
consideration the needs of individual residents, as assessed
and reported by the most current version of the nursing
facility Resident Assessment Instrument, adopted and in use by
the federal government.
    (d) A new nursing services reimbursement methodology
utilizing RUGs IV 48 grouper model shall be established and may
include an Illinois-specific default group, as needed. The new
RUGs-based nursing services reimbursement methodology shall be
resident-driven, facility-specific, and cost-based. Costs
shall be annually rebased and case mix index quarterly updated.
The methodology shall include regional wage adjustors based on
the Health Service Areas (HSA) groupings in effect on April 30,
2012. The Department shall assign a case mix index to each
resident class based on the Centers for Medicare and Medicaid
Services staff time measurement study utilizing an index
maximization approach.
    (e) Notwithstanding any other provision of this Code, the
Department shall by rule develop a reimbursement methodology
reflective of the intensity of care and services requirements
of low need residents in the lowest RUG IV groupers and
corresponding regulations.
    (f) Notwithstanding any other provision of this Code, on
and after July 1, 2012, reimbursement rates associated with the
nursing or support components of the current nursing facility
rate methodology shall not increase beyond the level effective
May 1, 2011 until a new reimbursement system based on the RUGs
IV 48 grouper model has been fully operationalized.
    (g) Notwithstanding any other provision of this Code, on
and after July 1, 2012, for facilities not designated by the
Department of Healthcare and Family Services as "Institutions
for Mental Disease", rates effective May 1, 2011 shall be
adjusted as follows:
        (1) Individual nursing rates for residents classified
    in RUG IV groups PA1, PA2, BA1, and BA2 during the quarter
    ending March 31, 2012 shall be reduced by 10%;
        (2) Individual nursing rates for residents classified
    in all other RUG IV groups shall be reduced by 1.0%;
        (3) Facility rates for the capital and support
    components shall be reduced by 1.7%.
    (h) Notwithstanding any other provision of this Code, on
and after July 1, 2012, nursing facilities designated by the
Department of Healthcare and Family Services as "Institutions
for Mental Disease" and "Institutions for Mental Disease" that
are facilities licensed under the Specialized Mental Health
Rehabilitation Act shall have the nursing,
socio-developmental, capital, and support components of their
reimbursement rate effective May 1, 2011 reduced in total by
2.7%.
(Source: P.A. 96-1530, eff. 2-16-11.)
 
    (305 ILCS 5/5-5.3)  (from Ch. 23, par. 5-5.3)
    Sec. 5-5.3. Conditions of Payment - Prospective Rates -
Accounting Principles. This amendatory Act establishes certain
conditions for the Department of Healthcare and Family Services
in instituting rates for the care of recipients of medical
assistance in nursing facilities and ICF/DDs. Such conditions
shall assure a method under which the payment for nursing
facility and ICF/DD services provided to recipients under the
Medical Assistance Program shall be on a reasonable cost
related basis, which is prospectively determined at least
annually by the Department of Public Aid (now Healthcare and
Family Services). The annually established payment rate shall
take effect on July 1 in 1984 and subsequent years. There shall
be no rate increase during calendar year 1983 and the first six
months of calendar year 1984.
    The determination of the payment shall be made on the basis
of generally accepted accounting principles that shall take
into account the actual costs to the facility of providing
nursing facility and ICF/DD services to recipients under the
medical assistance program.
    The resultant total rate for a specified type of service
shall be an amount which shall have been determined to be
adequate to reimburse allowable costs of a facility that is
economically and efficiently operated. The Department shall
establish an effective date for each facility or group of
facilities after which rates shall be paid on a reasonable cost
related basis which shall be no sooner than the effective date
of this amendatory Act of 1977.
    On and after July 1, 2012, the Department shall reduce any
rate of reimbursement for services or other payments or alter
any methodologies authorized by this Code to reduce any rate of
reimbursement for services or other payments in accordance with
Section 5-5e.
(Source: P.A. 95-331, eff. 8-21-07; 96-1530, eff. 2-16-11.)
 
    (305 ILCS 5/5-5.4)  (from Ch. 23, par. 5-5.4)
    Sec. 5-5.4. Standards of Payment - Department of Healthcare
and Family Services. The Department of Healthcare and Family
Services shall develop standards of payment of nursing facility
and ICF/DD services in facilities providing such services under
this Article which:
    (1) Provide for the determination of a facility's payment
for nursing facility or ICF/DD services on a prospective basis.
The amount of the payment rate for all nursing facilities
certified by the Department of Public Health under the ID/DD
Community Care Act or the Nursing Home Care Act as Intermediate
Care for the Developmentally Disabled facilities, Long Term
Care for Under Age 22 facilities, Skilled Nursing facilities,
or Intermediate Care facilities under the medical assistance
program shall be prospectively established annually on the
basis of historical, financial, and statistical data
reflecting actual costs from prior years, which shall be
applied to the current rate year and updated for inflation,
except that the capital cost element for newly constructed
facilities shall be based upon projected budgets. The annually
established payment rate shall take effect on July 1 in 1984
and subsequent years. No rate increase and no update for
inflation shall be provided on or after July 1, 1994 and before
January 1, 2014 July 1, 2012, unless specifically provided for
in this Section. The changes made by Public Act 93-841
extending the duration of the prohibition against a rate
increase or update for inflation are effective retroactive to
July 1, 2004.
    For facilities licensed by the Department of Public Health
under the Nursing Home Care Act as Intermediate Care for the
Developmentally Disabled facilities or Long Term Care for Under
Age 22 facilities, the rates taking effect on July 1, 1998
shall include an increase of 3%. For facilities licensed by the
Department of Public Health under the Nursing Home Care Act as
Skilled Nursing facilities or Intermediate Care facilities,
the rates taking effect on July 1, 1998 shall include an
increase of 3% plus $1.10 per resident-day, as defined by the
Department. For facilities licensed by the Department of Public
Health under the Nursing Home Care Act as Intermediate Care
Facilities for the Developmentally Disabled or Long Term Care
for Under Age 22 facilities, the rates taking effect on January
1, 2006 shall include an increase of 3%. For facilities
licensed by the Department of Public Health under the Nursing
Home Care Act as Intermediate Care Facilities for the
Developmentally Disabled or Long Term Care for Under Age 22
facilities, the rates taking effect on January 1, 2009 shall
include an increase sufficient to provide a $0.50 per hour wage
increase for non-executive staff.
    For facilities licensed by the Department of Public Health
under the Nursing Home Care Act as Intermediate Care for the
Developmentally Disabled facilities or Long Term Care for Under
Age 22 facilities, the rates taking effect on July 1, 1999
shall include an increase of 1.6% plus $3.00 per resident-day,
as defined by the Department. For facilities licensed by the
Department of Public Health under the Nursing Home Care Act as
Skilled Nursing facilities or Intermediate Care facilities,
the rates taking effect on July 1, 1999 shall include an
increase of 1.6% and, for services provided on or after October
1, 1999, shall be increased by $4.00 per resident-day, as
defined by the Department.
    For facilities licensed by the Department of Public Health
under the Nursing Home Care Act as Intermediate Care for the
Developmentally Disabled facilities or Long Term Care for Under
Age 22 facilities, the rates taking effect on July 1, 2000
shall include an increase of 2.5% per resident-day, as defined
by the Department. For facilities licensed by the Department of
Public Health under the Nursing Home Care Act as Skilled
Nursing facilities or Intermediate Care facilities, the rates
taking effect on July 1, 2000 shall include an increase of 2.5%
per resident-day, as defined by the Department.
    For facilities licensed by the Department of Public Health
under the Nursing Home Care Act as skilled nursing facilities
or intermediate care facilities, a new payment methodology must
be implemented for the nursing component of the rate effective
July 1, 2003. The Department of Public Aid (now Healthcare and
Family Services) shall develop the new payment methodology
using the Minimum Data Set (MDS) as the instrument to collect
information concerning nursing home resident condition
necessary to compute the rate. The Department shall develop the
new payment methodology to meet the unique needs of Illinois
nursing home residents while remaining subject to the
appropriations provided by the General Assembly. A transition
period from the payment methodology in effect on June 30, 2003
to the payment methodology in effect on July 1, 2003 shall be
provided for a period not exceeding 3 years and 184 days after
implementation of the new payment methodology as follows:
        (A) For a facility that would receive a lower nursing
    component rate per patient day under the new system than
    the facility received effective on the date immediately
    preceding the date that the Department implements the new
    payment methodology, the nursing component rate per
    patient day for the facility shall be held at the level in
    effect on the date immediately preceding the date that the
    Department implements the new payment methodology until a
    higher nursing component rate of reimbursement is achieved
    by that facility.
        (B) For a facility that would receive a higher nursing
    component rate per patient day under the payment
    methodology in effect on July 1, 2003 than the facility
    received effective on the date immediately preceding the
    date that the Department implements the new payment
    methodology, the nursing component rate per patient day for
    the facility shall be adjusted.
        (C) Notwithstanding paragraphs (A) and (B), the
    nursing component rate per patient day for the facility
    shall be adjusted subject to appropriations provided by the
    General Assembly.
    For facilities licensed by the Department of Public Health
under the Nursing Home Care Act as Intermediate Care for the
Developmentally Disabled facilities or Long Term Care for Under
Age 22 facilities, the rates taking effect on March 1, 2001
shall include a statewide increase of 7.85%, as defined by the
Department.
    Notwithstanding any other provision of this Section, for
facilities licensed by the Department of Public Health under
the Nursing Home Care Act as skilled nursing facilities or
intermediate care facilities, except facilities participating
in the Department's demonstration program pursuant to the
provisions of Title 77, Part 300, Subpart T of the Illinois
Administrative Code, the numerator of the ratio used by the
Department of Healthcare and Family Services to compute the
rate payable under this Section using the Minimum Data Set
(MDS) methodology shall incorporate the following annual
amounts as the additional funds appropriated to the Department
specifically to pay for rates based on the MDS nursing
component methodology in excess of the funding in effect on
December 31, 2006:
        (i) For rates taking effect January 1, 2007,
    $60,000,000.
        (ii) For rates taking effect January 1, 2008,
    $110,000,000.
        (iii) For rates taking effect January 1, 2009,
    $194,000,000.
        (iv) For rates taking effect April 1, 2011, or the
    first day of the month that begins at least 45 days after
    the effective date of this amendatory Act of the 96th
    General Assembly, $416,500,000 or an amount as may be
    necessary to complete the transition to the MDS methodology
    for the nursing component of the rate. Increased payments
    under this item (iv) are not due and payable, however,
    until (i) the methodologies described in this paragraph are
    approved by the federal government in an appropriate State
    Plan amendment and (ii) the assessment imposed by Section
    5B-2 of this Code is determined to be a permissible tax
    under Title XIX of the Social Security Act.
    Notwithstanding any other provision of this Section, for
facilities licensed by the Department of Public Health under
the Nursing Home Care Act as skilled nursing facilities or
intermediate care facilities, the support component of the
rates taking effect on January 1, 2008 shall be computed using
the most recent cost reports on file with the Department of
Healthcare and Family Services no later than April 1, 2005,
updated for inflation to January 1, 2006.
    For facilities licensed by the Department of Public Health
under the Nursing Home Care Act as Intermediate Care for the
Developmentally Disabled facilities or Long Term Care for Under
Age 22 facilities, the rates taking effect on April 1, 2002
shall include a statewide increase of 2.0%, as defined by the
Department. This increase terminates on July 1, 2002; beginning
July 1, 2002 these rates are reduced to the level of the rates
in effect on March 31, 2002, as defined by the Department.
    For facilities licensed by the Department of Public Health
under the Nursing Home Care Act as skilled nursing facilities
or intermediate care facilities, the rates taking effect on
July 1, 2001 shall be computed using the most recent cost
reports on file with the Department of Public Aid no later than
April 1, 2000, updated for inflation to January 1, 2001. For
rates effective July 1, 2001 only, rates shall be the greater
of the rate computed for July 1, 2001 or the rate effective on
June 30, 2001.
    Notwithstanding any other provision of this Section, for
facilities licensed by the Department of Public Health under
the Nursing Home Care Act as skilled nursing facilities or
intermediate care facilities, the Illinois Department shall
determine by rule the rates taking effect on July 1, 2002,
which shall be 5.9% less than the rates in effect on June 30,
2002.
    Notwithstanding any other provision of this Section, for
facilities licensed by the Department of Public Health under
the Nursing Home Care Act as skilled nursing facilities or
intermediate care facilities, if the payment methodologies
required under Section 5A-12 and the waiver granted under 42
CFR 433.68 are approved by the United States Centers for
Medicare and Medicaid Services, the rates taking effect on July
1, 2004 shall be 3.0% greater than the rates in effect on June
30, 2004. These rates shall take effect only upon approval and
implementation of the payment methodologies required under
Section 5A-12.
    Notwithstanding any other provisions of this Section, for
facilities licensed by the Department of Public Health under
the Nursing Home Care Act as skilled nursing facilities or
intermediate care facilities, the rates taking effect on
January 1, 2005 shall be 3% more than the rates in effect on
December 31, 2004.
    Notwithstanding any other provision of this Section, for
facilities licensed by the Department of Public Health under
the Nursing Home Care Act as skilled nursing facilities or
intermediate care facilities, effective January 1, 2009, the
per diem support component of the rates effective on January 1,
2008, computed using the most recent cost reports on file with
the Department of Healthcare and Family Services no later than
April 1, 2005, updated for inflation to January 1, 2006, shall
be increased to the amount that would have been derived using
standard Department of Healthcare and Family Services methods,
procedures, and inflators.
    Notwithstanding any other provisions of this Section, for
facilities licensed by the Department of Public Health under
the Nursing Home Care Act as intermediate care facilities that
are federally defined as Institutions for Mental Disease, or
facilities licensed by the Department of Public Health under
the Specialized Mental Health Rehabilitation Facilities Act, a
socio-development component rate equal to 6.6% of the
facility's nursing component rate as of January 1, 2006 shall
be established and paid effective July 1, 2006. The
socio-development component of the rate shall be increased by a
factor of 2.53 on the first day of the month that begins at
least 45 days after January 11, 2008 (the effective date of
Public Act 95-707). As of August 1, 2008, the socio-development
component rate shall be equal to 6.6% of the facility's nursing
component rate as of January 1, 2006, multiplied by a factor of
3.53. For services provided on or after April 1, 2011, or the
first day of the month that begins at least 45 days after the
effective date of this amendatory Act of the 96th General
Assembly, whichever is later, the Illinois Department may by
rule adjust these socio-development component rates, and may
use different adjustment methodologies for those facilities
participating, and those not participating, in the Illinois
Department's demonstration program pursuant to the provisions
of Title 77, Part 300, Subpart T of the Illinois Administrative
Code, but in no case may such rates be diminished below those
in effect on August 1, 2008.
    For facilities licensed by the Department of Public Health
under the Nursing Home Care Act as Intermediate Care for the
Developmentally Disabled facilities or as long-term care
facilities for residents under 22 years of age, the rates
taking effect on July 1, 2003 shall include a statewide
increase of 4%, as defined by the Department.
    For facilities licensed by the Department of Public Health
under the Nursing Home Care Act as Intermediate Care for the
Developmentally Disabled facilities or Long Term Care for Under
Age 22 facilities, the rates taking effect on the first day of
the month that begins at least 45 days after the effective date
of this amendatory Act of the 95th General Assembly shall
include a statewide increase of 2.5%, as defined by the
Department.
    Notwithstanding any other provision of this Section, for
facilities licensed by the Department of Public Health under
the Nursing Home Care Act as skilled nursing facilities or
intermediate care facilities, effective January 1, 2005,
facility rates shall be increased by the difference between (i)
a facility's per diem property, liability, and malpractice
insurance costs as reported in the cost report filed with the
Department of Public Aid and used to establish rates effective
July 1, 2001 and (ii) those same costs as reported in the
facility's 2002 cost report. These costs shall be passed
through to the facility without caps or limitations, except for
adjustments required under normal auditing procedures.
    Rates established effective each July 1 shall govern
payment for services rendered throughout that fiscal year,
except that rates established on July 1, 1996 shall be
increased by 6.8% for services provided on or after January 1,
1997. Such rates will be based upon the rates calculated for
the year beginning July 1, 1990, and for subsequent years
thereafter until June 30, 2001 shall be based on the facility
cost reports for the facility fiscal year ending at any point
in time during the previous calendar year, updated to the
midpoint of the rate year. The cost report shall be on file
with the Department no later than April 1 of the current rate
year. Should the cost report not be on file by April 1, the
Department shall base the rate on the latest cost report filed
by each skilled care facility and intermediate care facility,
updated to the midpoint of the current rate year. In
determining rates for services rendered on and after July 1,
1985, fixed time shall not be computed at less than zero. The
Department shall not make any alterations of regulations which
would reduce any component of the Medicaid rate to a level
below what that component would have been utilizing in the rate
effective on July 1, 1984.
    (2) Shall take into account the actual costs incurred by
facilities in providing services for recipients of skilled
nursing and intermediate care services under the medical
assistance program.
    (3) Shall take into account the medical and psycho-social
characteristics and needs of the patients.
    (4) Shall take into account the actual costs incurred by
facilities in meeting licensing and certification standards
imposed and prescribed by the State of Illinois, any of its
political subdivisions or municipalities and by the U.S.
Department of Health and Human Services pursuant to Title XIX
of the Social Security Act.
    The Department of Healthcare and Family Services shall
develop precise standards for payments to reimburse nursing
facilities for any utilization of appropriate rehabilitative
personnel for the provision of rehabilitative services which is
authorized by federal regulations, including reimbursement for
services provided by qualified therapists or qualified
assistants, and which is in accordance with accepted
professional practices. Reimbursement also may be made for
utilization of other supportive personnel under appropriate
supervision.
    The Department shall develop enhanced payments to offset
the additional costs incurred by a facility serving exceptional
need residents and shall allocate at least $8,000,000 of the
funds collected from the assessment established by Section 5B-2
of this Code for such payments. For the purpose of this
Section, "exceptional needs" means, but need not be limited to,
ventilator care, tracheotomy care, bariatric care, complex
wound care, and traumatic brain injury care. The enhanced
payments for exceptional need residents under this paragraph
are not due and payable, however, until (i) the methodologies
described in this paragraph are approved by the federal
government in an appropriate State Plan amendment and (ii) the
assessment imposed by Section 5B-2 of this Code is determined
to be a permissible tax under Title XIX of the Social Security
Act.
    (5) Beginning January July 1, 2014 2012 the methodologies
for reimbursement of nursing facility services as provided
under this Section 5-5.4 shall no longer be applicable for
services provided on or after January 1, 2014 bills payable for
State fiscal years 2012 and thereafter.
    (6) No payment increase under this Section for the MDS
methodology, exceptional care residents, or the
socio-development component rate established by Public Act
96-1530 of the 96th General Assembly and funded by the
assessment imposed under Section 5B-2 of this Code shall be due
and payable until after the Department notifies the long-term
care providers, in writing, that the payment methodologies to
long-term care providers required under this Section have been
approved by the Centers for Medicare and Medicaid Services of
the U.S. Department of Health and Human Services and the
waivers under 42 CFR 433.68 for the assessment imposed by this
Section, if necessary, have been granted by the Centers for
Medicare and Medicaid Services of the U.S. Department of Health
and Human Services. Upon notification to the Department of
approval of the payment methodologies required under this
Section and the waivers granted under 42 CFR 433.68, all
increased payments otherwise due under this Section prior to
the date of notification shall be due and payable within 90
days of the date federal approval is received.
    On and after July 1, 2012, the Department shall reduce any
rate of reimbursement for services or other payments or alter
any methodologies authorized by this Code to reduce any rate of
reimbursement for services or other payments in accordance with
Section 5-5e.
(Source: P.A. 96-45, eff. 7-15-09; 96-339, eff. 7-1-10; 96-959,
eff. 7-1-10; 96-1000, eff. 7-2-10; 96-1530, eff. 2-16-11;
97-10, eff. 6-14-11; 97-38, eff. 6-28-11; 97-227, eff. 1-1-12;
97-584, eff. 8-26-11; revised 10-4-11.)
 
    (305 ILCS 5/5-5.4e)
    Sec. 5-5.4e. Nursing facilities; ventilator rates. On and
after October 1, 2009, the Department of Healthcare and Family
Services shall adopt rules to provide medical assistance
reimbursement under this Article for the care of persons on
ventilators in skilled nursing facilities licensed under the
Nursing Home Care Act and certified to participate under the
medical assistance program. Accordingly, necessary amendments
to the rules implementing the Minimum Data Set (MDS) payment
methodology shall also be made to provide a separate per diem
ventilator rate based on days of service. The Department may
adopt rules necessary to implement this amendatory Act of the
96th General Assembly through the use of emergency rulemaking
in accordance with Section 5-45 of the Illinois Administrative
Procedure Act, except that the 24-month limitation on the
adoption of emergency rules under Section 5-45 and the
provisions of Sections 5-115 and 5-125 of that Act do not apply
to rules adopted under this Section. For purposes of that Act,
the General Assembly finds that the adoption of rules to
implement this amendatory Act of the 96th General Assembly is
deemed an emergency and necessary for the public interest,
safety, and welfare.
    On and after July 1, 2012, the Department shall reduce any
rate of reimbursement for services or other payments or alter
any methodologies authorized by this Code to reduce any rate of
reimbursement for services or other payments in accordance with
Section 5-5e.
(Source: P.A. 96-743, eff. 8-25-09.)
 
    (305 ILCS 5/5-5.5)  (from Ch. 23, par. 5-5.5)
    Sec. 5-5.5. Elements of Payment Rate.
    (a) The Department of Healthcare and Family Services shall
develop a prospective method for determining payment rates for
nursing facility and ICF/DD services in nursing facilities
composed of the following cost elements:
        (1) Standard Services, with the cost of this component
    being determined by taking into account the actual costs to
    the facilities of these services subject to cost ceilings
    to be defined in the Department's rules.
        (2) Resident Services, with the cost of this component
    being determined by taking into account the actual costs,
    needs and utilization of these services, as derived from an
    assessment of the resident needs in the nursing facilities.
        (3) Ancillary Services, with the payment rate being
    developed for each individual type of service. Payment
    shall be made only when authorized under procedures
    developed by the Department of Healthcare and Family
    Services.
        (4) Nurse's Aide Training, with the cost of this
    component being determined by taking into account the
    actual cost to the facilities of such training.
        (5) Real Estate Taxes, with the cost of this component
    being determined by taking into account the figures
    contained in the most currently available cost reports
    (with no imposition of maximums) updated to the midpoint of
    the current rate year for long term care services rendered
    between July 1, 1984 and June 30, 1985, and with the cost
    of this component being determined by taking into account
    the actual 1983 taxes for which the nursing homes were
    assessed (with no imposition of maximums) updated to the
    midpoint of the current rate year for long term care
    services rendered between July 1, 1985 and June 30, 1986.
    (b) In developing a prospective method for determining
payment rates for nursing facility and ICF/DD services in
nursing facilities and ICF/DDs, the Department of Healthcare
and Family Services shall consider the following cost elements:
        (1) Reasonable capital cost determined by utilizing
    incurred interest rate and the current value of the
    investment, including land, utilizing composite rates, or
    by utilizing such other reasonable cost related methods
    determined by the Department. However, beginning with the
    rate reimbursement period effective July 1, 1987, the
    Department shall be prohibited from establishing,
    including, and implementing any depreciation factor in
    calculating the capital cost element.
        (2) Profit, with the actual amount being produced and
    accruing to the providers in the form of a return on their
    total investment, on the basis of their ability to
    economically and efficiently deliver a type of service. The
    method of payment may assure the opportunity for a profit,
    but shall not guarantee or establish a specific amount as a
    cost.
    (c) The Illinois Department may implement the amendatory
changes to this Section made by this amendatory Act of 1991
through the use of emergency rules in accordance with the
provisions of Section 5.02 of the Illinois Administrative
Procedure Act. For purposes of the Illinois Administrative
Procedure Act, the adoption of rules to implement the
amendatory changes to this Section made by this amendatory Act
of 1991 shall be deemed an emergency and necessary for the
public interest, safety and welfare.
    (d) No later than January 1, 2001, the Department of Public
Aid shall file with the Joint Committee on Administrative
Rules, pursuant to the Illinois Administrative Procedure Act, a
proposed rule, or a proposed amendment to an existing rule,
regarding payment for appropriate services, including
assessment, care planning, discharge planning, and treatment
provided by nursing facilities to residents who have a serious
mental illness.
    (e) On and after July 1, 2012, the Department shall reduce
any rate of reimbursement for services or other payments or
alter any methodologies authorized by this Code to reduce any
rate of reimbursement for services or other payments in
accordance with Section 5-5e.
(Source: P.A. 95-331, eff. 8-21-07; 96-1123, eff. 1-1-11;
96-1530, eff. 2-16-11.)
 
    (305 ILCS 5/5-5.8b)  (from Ch. 23, par. 5-5.8b)
    Sec. 5-5.8b. Payment to Campus Facilities. There is hereby
established a separate payment category for campus facilities.
A "campus facility" is defined as an entity which consists of a
long term care facility (or group of facilities if the
facilities are on the same contiguous parcel of real estate)
which meets all of the following criteria as of May 1, 1987:
the entity provides care for both children and adults;
residents of the entity reside in three or more separate
buildings with congregate and small group living arrangements
on a single campus; the entity provides three or more separate
licensed levels of care; the entity (or a part of the entity)
is enrolled with the Department of Healthcare and Family
Services as a provider of long term care services and receives
payments from that Department; the entity (or a part of the
entity) receives funding from the Department of Human Services;
and the entity (or a part of the entity) holds a current
license as a child care institution issued by the Department of
Children and Family Services.
    The Department of Healthcare and Family Services, the
Department of Human Services, and the Department of Children
and Family Services shall develop jointly a rate methodology or
methodologies for campus facilities. Such methodology or
methodologies may establish a single rate to be paid by all the
agencies, or a separate rate to be paid by each agency, or
separate components to be paid to different parts of the campus
facility. All campus facilities shall receive the same rate of
payment for similar services. Any methodology developed
pursuant to this section shall take into account the actual
costs to the facility of providing services to residents, and
shall be adequate to reimburse the allowable costs of a campus
facility which is economically and efficiently operated. Any
methodology shall be established on the basis of historical,
financial, and statistical data submitted by campus
facilities, and shall take into account the actual costs
incurred by campus facilities in providing services, and in
meeting licensing and certification standards imposed and
prescribed by the State of Illinois, any of its political
subdivisions or municipalities and by the United States
Department of Health and Human Services. Rates may be
established on a prospective or retrospective basis. Any
methodology shall provide reimbursement for appropriate
payment elements, including the following: standard services,
patient services, real estate taxes, and capital costs.
    On and after July 1, 2012, the Department shall reduce any
rate of reimbursement for services or other payments or alter
any methodologies authorized by this Code to reduce any rate of
reimbursement for services or other payments in accordance with
Section 5-5e.
(Source: P.A. 95-331, eff. 8-21-07; 96-1530, eff. 2-16-11.)
 
    (305 ILCS 5/5-5.12)  (from Ch. 23, par. 5-5.12)
    Sec. 5-5.12. Pharmacy payments.
    (a) Every request submitted by a pharmacy for reimbursement
under this Article for prescription drugs provided to a
recipient of aid under this Article shall include the name of
the prescriber or an acceptable identification number as
established by the Department.
    (b) Pharmacies providing prescription drugs under this
Article shall be reimbursed at a rate which shall include a
professional dispensing fee as determined by the Illinois
Department, plus the current acquisition cost of the
prescription drug dispensed. The Illinois Department shall
update its information on the acquisition costs of all
prescription drugs no less frequently than every 30 days.
However, the Illinois Department may set the rate of
reimbursement for the acquisition cost, by rule, at a
percentage of the current average wholesale acquisition cost.
    (c) (Blank).
    (d) The Department shall not impose requirements for prior
approval based on a preferred drug list for anti-retroviral,
anti-hemophilic factor concentrates, or any atypical
antipsychotics, conventional antipsychotics, or
anticonvulsants used for the treatment of serious mental
illnesses until 30 days after it has conducted a study of the
impact of such requirements on patient care and submitted a
report to the Speaker of the House of Representatives and the
President of the Senate. The Department shall review
utilization of narcotic medications in the medical assistance
program and impose utilization controls that protect against
abuse.
    (e) When making determinations as to which drugs shall be
on a prior approval list, the Department shall include as part
of the analysis for this determination, the degree to which a
drug may affect individuals in different ways based on factors
including the gender of the person taking the medication.
    (f) The Department shall cooperate with the Department of
Public Health and the Department of Human Services Division of
Mental Health in identifying psychotropic medications that,
when given in a particular form, manner, duration, or frequency
(including "as needed") in a dosage, or in conjunction with
other psychotropic medications to a nursing home resident or to
a resident of a facility licensed under the ID/DD MR/DD
Community Care Act, may constitute a chemical restraint or an
"unnecessary drug" as defined by the Nursing Home Care Act or
Titles XVIII and XIX of the Social Security Act and the
implementing rules and regulations. The Department shall
require prior approval for any such medication prescribed for a
nursing home resident or to a resident of a facility licensed
under the ID/DD MR/DD Community Care Act, that appears to be a
chemical restraint or an unnecessary drug. The Department shall
consult with the Department of Human Services Division of
Mental Health in developing a protocol and criteria for
deciding whether to grant such prior approval.
    (g) The Department may by rule provide for reimbursement of
the dispensing of a 90-day supply of a generic or brand name,
non-narcotic maintenance medication in circumstances where it
is cost effective.
    (g-5) On and after July 1, 2012, the Department may require
the dispensing of drugs to nursing home residents be in a 7-day
supply or other amount less than a 31-day supply. The
Department shall pay only one dispensing fee per 31-day supply.
    (h) Effective July 1, 2011, the Department shall
discontinue coverage of select over-the-counter drugs,
including analgesics and cough and cold and allergy
medications.
    (h-5) On and after July 1, 2012, the Department shall
impose utilization controls, including, but not limited to,
prior approval on specialty drugs, oncolytic drugs, drugs for
the treatment of HIV or AIDS, immunosuppressant drugs, and
biological products in order to maximize savings on these
drugs. The Department may adjust payment methodologies for
non-pharmacy billed drugs in order to incentivize the selection
of lower-cost drugs. For drugs for the treatment of AIDS, the
Department shall take into consideration the potential for
non-adherence by certain populations, and shall develop
protocols with organizations or providers primarily serving
those with HIV/AIDS, as long as such measures intend to
maintain cost neutrality with other utilization management
controls such as prior approval. For hemophilia, the Department
shall develop a program of utilization review and control which
may include, in the discretion of the Department, prior
approvals. The Department may impose special standards on
providers that dispense blood factors which shall include, in
the discretion of the Department, staff training and education;
patient outreach and education; case management; in-home
patient assessments; assay management; maintenance of stock;
emergency dispensing timeframes; data collection and
reporting; dispensing of supplies related to blood factor
infusions; cold chain management and packaging practices; care
coordination; product recalls; and emergency clinical
consultation. The Department may require patients to receive a
comprehensive examination annually at an appropriate provider
in order to be eligible to continue to receive blood factor.
    (i) On and after July 1, 2012, the Department shall reduce
any rate of reimbursement for services or other payments or
alter any methodologies authorized by this Code to reduce any
rate of reimbursement for services or other payments in
accordance with Section 5-5e.
    (i) (Blank). The Department shall seek any necessary waiver
from the federal government in order to establish a program
limiting the pharmacies eligible to dispense specialty drugs
and shall issue a Request for Proposals in order to maximize
savings on these drugs. The Department shall by rule establish
the drugs required to be dispensed in this program.
    (j) On and after July 1, 2012, the Department shall impose
limitations on prescription drugs such that the Department
shall not provide reimbursement for more than 4 prescriptions,
including 3 brand name prescriptions, for distinct drugs in a
30-day period, unless prior approval is received for all
prescriptions in excess of the 4-prescription limit. Drugs in
the following therapeutic classes shall not be subject to prior
approval as a result of the 4-prescription limit:
immunosuppressant drugs, oncolytic drugs, and anti-retroviral
drugs.
    (k) No medication therapy management program implemented
by the Department shall be contrary to the provisions of the
Pharmacy Practice Act.
    (l) Any provider enrolled with the Department that bills
the Department for outpatient drugs and is eligible to enroll
in the federal Drug Pricing Program under Section 340B of the
federal Public Health Services Act shall enroll in that
program. No entity participating in the federal Drug Pricing
Program under Section 340B of the federal Public Health
Services Act may exclude Medicaid from their participation in
that program, although the Department may exclude entities
defined in Section 1905(l)(2)(B) of the Social Security Act
from this requirement.
(Source: P.A. 96-1269, eff. 7-26-10; 96-1372, eff. 7-29-10;
96-1501, eff. 1-25-11; 97-38, eff. 6-28-11; 97-74, eff.
6-30-11; 97-333, eff. 8-12-11; 97-426, eff. 1-1-12; revised
10-4-11.)
 
    (305 ILCS 5/5-5.17)  (from Ch. 23, par. 5-5.17)
    Sec. 5-5.17. Separate reimbursement rate. The Illinois
Department may by rule establish a separate reimbursement rate
to be paid to long term care facilities for adult developmental
training services as defined in Section 15.2 of the Mental
Health and Developmental Disabilities Administrative Act which
are provided to intellectually disabled residents of such
facilities who receive aid under this Article. Any such
reimbursement shall be based upon cost reports submitted by the
providers of such services and shall be paid by the long term
care facility to the provider within such time as the Illinois
Department shall prescribe by rule, but in no case less than 3
business days after receipt of the reimbursement by such
facility from the Illinois Department. The Illinois Department
may impose a penalty upon a facility which does not make
payment to the provider of adult developmental training
services within the time so prescribed, up to the amount of
payment not made to the provider.
    On and after July 1, 2012, the Department shall reduce any
rate of reimbursement for services or other payments or alter
any methodologies authorized by this Code to reduce any rate of
reimbursement for services or other payments in accordance with
Section 5-5e.
(Source: P.A. 97-227, eff. 1-1-12.)
 
    (305 ILCS 5/5-5.20)
    Sec. 5-5.20. Clinic payments. For services provided by
federally qualified health centers as defined in Section 1905
(l)(2)(B) of the federal Social Security Act, on or after April
1, 1989, and as long as required by federal law, the Illinois
Department shall reimburse those health centers for those
services according to a prospective cost-reimbursement
methodology.
    On and after July 1, 2012, the Department shall reduce any
rate of reimbursement for services or other payments or alter
any methodologies authorized by this Code to reduce any rate of
reimbursement for services or other payments in accordance with
Section 5-5e.
(Source: P.A. 89-38, eff. 1-1-96.)
 
    (305 ILCS 5/5-5.23)
    Sec. 5-5.23. Children's mental health services.
    (a) The Department of Healthcare and Family Services, by
rule, shall require the screening and assessment of a child
prior to any Medicaid-funded admission to an inpatient hospital
for psychiatric services to be funded by Medicaid. The
screening and assessment shall include a determination of the
appropriateness and availability of out-patient support
services for necessary treatment. The Department, by rule,
shall establish methods and standards of payment for the
screening, assessment, and necessary alternative support
services.
    (b) The Department of Healthcare and Family Services, to
the extent allowable under federal law, shall secure federal
financial participation for Individual Care Grant expenditures
made by the Department of Human Services for the Medicaid
optional service authorized under Section 1905(h) of the
federal Social Security Act, pursuant to the provisions of
Section 7.1 of the Mental Health and Developmental Disabilities
Administrative Act.
    (c) The Department of Healthcare and Family Services shall
work jointly with the Department of Human Services to implement
subsections (a) and (b).
    (d) On and after July 1, 2012, the Department shall reduce
any rate of reimbursement for services or other payments or
alter any methodologies authorized by this Code to reduce any
rate of reimbursement for services or other payments in
accordance with Section 5-5e.
(Source: P.A. 95-331, eff. 8-21-07.)
 
    (305 ILCS 5/5-5.24)
    Sec. 5-5.24. Prenatal and perinatal care. The Department of
Healthcare and Family Services may provide reimbursement under
this Article for all prenatal and perinatal health care
services that are provided for the purpose of preventing
low-birthweight infants, reducing the need for neonatal
intensive care hospital services, and promoting perinatal
health. These services may include comprehensive risk
assessments for pregnant women, women with infants, and
infants, lactation counseling, nutrition counseling,
childbirth support, psychosocial counseling, treatment and
prevention of periodontal disease, and other support services
that have been proven to improve birth outcomes. The Department
shall maximize the use of preventive prenatal and perinatal
health care services consistent with federal statutes, rules,
and regulations. The Department of Public Aid (now Department
of Healthcare and Family Services) shall develop a plan for
prenatal and perinatal preventive health care and shall present
the plan to the General Assembly by January 1, 2004. On or
before January 1, 2006 and every 2 years thereafter, the
Department shall report to the General Assembly concerning the
effectiveness of prenatal and perinatal health care services
reimbursed under this Section in preventing low-birthweight
infants and reducing the need for neonatal intensive care
hospital services. Each such report shall include an evaluation
of how the ratio of expenditures for treating low-birthweight
infants compared with the investment in promoting healthy
births and infants in local community areas throughout Illinois
relates to healthy infant development in those areas.
    On and after July 1, 2012, the Department shall reduce any
rate of reimbursement for services or other payments or alter
any methodologies authorized by this Code to reduce any rate of
reimbursement for services or other payments in accordance with
Section 5-5e.
(Source: P.A. 95-331, eff. 8-21-07.)
 
    (305 ILCS 5/5-5.25)
    Sec. 5-5.25. Access to psychiatric mental health services.
The General Assembly finds that providing access to psychiatric
mental health services in a timely manner will improve the
quality of life for persons suffering from mental illness and
will contain health care costs by avoiding the need for more
costly inpatient hospitalization. The Department of Healthcare
and Family Services shall reimburse psychiatrists and
federally qualified health centers as defined in Section
1905(l)(2)(B) of the federal Social Security Act for mental
health services provided by psychiatrists, as authorized by
Illinois law, to recipients via telepsychiatry. The
Department, by rule, shall establish (i) criteria for such
services to be reimbursed, including appropriate facilities
and equipment to be used at both sites and requirements for a
physician or other licensed health care professional to be
present at the site where the patient is located, and (ii) a
method to reimburse providers for mental health services
provided by telepsychiatry.
    On and after July 1, 2012, the Department shall reduce any
rate of reimbursement for services or other payments or alter
any methodologies authorized by this Code to reduce any rate of
reimbursement for services or other payments in accordance with
Section 5-5e.
(Source: P.A. 95-16, eff. 7-18-07.)
 
    (305 ILCS 5/5-5e new)
    Sec. 5-5e. Adjusted rates of reimbursement.
    (a) Rates or payments for services in effect on June 30,
2012 shall be adjusted and services shall be affected as
required by any other provision of this amendatory Act of the
97th General Assembly. In addition, the Department shall do the
following:
        (1) Delink the per diem rate paid for supportive living
    facility services from the per diem rate paid for nursing
    facility services, effective for services provided on or
    after May 1, 2011.
        (2) Cease payment for bed reserves in nursing
    facilities, specialized mental health rehabilitation
    facilities, and, except in the instance of residents who
    are under 21 years of age, intermediate care facilities for
    persons with developmental disabilities.
        (3) Cease payment of the $10 per day add-on payment to
    nursing facilities for certain residents with
    developmental disabilities.
    (b) After the application of subsection (a),
notwithstanding any other provision of this Code to the
contrary and to the extent permitted by federal law, on and
after July 1, 2012, the rates of reimbursement for services and
other payments provided under this Code shall further be
reduced as follows:
        (1) Rates or payments for physician services, dental
    services, or community health center services reimbursed
    through an encounter rate, and services provided under the
    Medicaid Rehabilitation Option of the Illinois Title XIX
    State Plan shall not be further reduced.
        (2) Rates or payments, or the portion thereof, paid to
    a provider that is operated by a unit of local government
    or State University that provides the non-federal share of
    such services shall not be further reduced.
        (3) Rates or payments for hospital services delivered
    by a hospital defined as a Safety-Net Hospital under
    Section 5-5e.1 of this Code shall not be further reduced.
        (4) Rates or payments for hospital services delivered
    by a Critical Access Hospital, which is an Illinois
    hospital designated as a critical care hospital by the
    Department of Public Health in accordance with 42 CFR 485,
    Subpart F, shall not be further reduced.
        (5) Rates or payments for Nursing Facility Services
    shall only be further adjusted pursuant to Section 5-5.2 of
    this Code.
        (6) Rates or payments for services delivered by long
    term care facilities licensed under the ID/DD Community
    Care Act and developmental training services shall not be
    further reduced.
        (7) Rates or payments for services provided under
    capitation rates shall be adjusted taking into
    consideration the rates reduction and covered services
    required by this amendatory Act of the 97th General
    Assembly.
        (8) For hospitals not previously described in this
    subsection, the rates or payments for hospital services
    shall be further reduced by 3.5%, except for payments
    authorized under Section 5A-12.4 of this Code.
        (9) For all other rates or payments for services
    delivered by providers not specifically referenced in
    paragraphs (1) through (8), rates or payments shall be
    further reduced by 2.7%.
    (c) Any assessment imposed by this Code shall continue and
nothing in this Section shall be construed to cause it to
cease.
 
    (305 ILCS 5/5-5e.1 new)
    Sec. 5-5e.1. Safety-Net Hospitals.
    (a) A Safety-Net Hospital is an Illinois hospital that:
        (1) is licensed by the Department of Public Health as a
    general acute care or pediatric hospital; and
        (2) is a disproportionate share hospital, as described
    in Section 1923 of the federal Social Security Act, as
    determined by the Department; and
        (3) meets one of the following:
            (A) has a MIUR of at least 40% and a charity
        percent of at least 4%; or
            (B) has a MIUR of at least 50%.
    (b) Definitions. As used in this Section:
        (1) "Charity percent" means the ratio of (i) the
    hospital's charity charges for services provided to
    individuals without health insurance or another source of
    third party coverage to (ii) the Illinois total hospital
    charges, each as reported on the hospital's OBRA form.
        (2) "MIUR" means Medicaid Inpatient Utilization Rate
    and is defined as a fraction, the numerator of which is the
    number of a hospital's inpatient days provided in the
    hospital's fiscal year ending 3 years prior to the rate
    year, to patients who, for such days, were eligible for
    Medicaid under Title XIX of the federal Social Security
    Act, 42 USC 1396a et seq., and the denominator of which is
    the total number of the hospital's inpatient days in that
    same period.
        (3) "OBRA form" means form HFS-3834, OBRA '93 data
    collection form, for the rate year.
        (4) "Rate year" means the 12-month period beginning on
    October 1.
    (c) For the 27-month period beginning July 1, 2012, a
hospital that would have qualified for the rate year beginning
October 1, 2011, shall be a Safety-Net Hospital.
    (d) No later than August 15 preceding the rate year, each
hospital shall submit the OBRA form to the Department. Prior to
October 1, the Department shall notify each hospital whether it
has qualified as a Safety-Net Hospital.
    (e) The Department may promulgate rules in order to
implement this Section.
 
    (305 ILCS 5/5-5f new)
    Sec. 5-5f. Elimination and limitations of medical
assistance services. Notwithstanding any other provision of
this Code to the contrary, on and after July 1, 2012:
    (a) The following services shall no longer be a covered
service available under this Code: group psychotherapy for
residents of any facility licensed under the Nursing Home Care
Act or the Specialized Mental Health Rehabilitation Act; and
adult chiropractic services.
    (b) The Department shall place the following limitations on
services: (i) the Department shall limit adult eyeglasses to
one pair every 2 years; (ii) the Department shall set an annual
limit of a maximum of 20 visits for each of the following
services: adult speech, hearing, and language therapy
services, adult occupational therapy services, and physical
therapy services; (iii) the Department shall limit podiatry
services to individuals with diabetes; (iv) the Department
shall pay for caesarean sections at the normal vaginal delivery
rate unless a caesarean section was medically necessary; (v)
the Department shall limit adult dental services to
emergencies; and (vi) effective July 1, 2012, the Department
shall place limitations and require concurrent review on every
inpatient detoxification stay to prevent repeat admissions to
any hospital for detoxification within 60 days of a previous
inpatient detoxification stay. The Department shall convene a
workgroup of hospitals, substance abuse providers, care
coordination entities, managed care plans, and other
stakeholders to develop recommendations for quality standards,
diversion to other settings, and admission criteria for
patients who need inpatient detoxification.
    (c) The Department shall require prior approval of the
following services: wheelchair repairs, regardless of the cost
of the repairs, coronary artery bypass graft, and bariatric
surgery consistent with Medicare standards concerning patient
responsibility. The wholesale cost of power wheelchairs shall
be actual acquisition cost including all discounts.
    (d) The Department shall establish benchmarks for
hospitals to measure and align payments to reduce potentially
preventable hospital readmissions, inpatient complications,
and unnecessary emergency room visits. In doing so, the
Department shall consider items, including, but not limited to,
historic and current acuity of care and historic and current
trends in readmission. The Department shall publish
provider-specific historical readmission data and anticipated
potentially preventable targets 60 days prior to the start of
the program. In the instance of readmissions, the Department
shall adopt policies and rates of reimbursement for services
and other payments provided under this Code to ensure that, by
June 30, 2013, expenditures to hospitals are reduced by, at a
minimum, $40,000,000.
    (e) The Department shall establish utilization controls
for the hospice program such that it shall not pay for other
care services when an individual is in hospice.
    (f) For home health services, the Department shall require
Medicare certification of providers participating in the
program, implement the Medicare face-to-face encounter rule,
and limit services to post-hospitalization. The Department
shall require providers to implement auditable electronic
service verification based on global positioning systems or
other cost-effective technology.
    (g) For the Home Services Program operated by the
Department of Human Services and the Community Care Program
operated by the Department on Aging, the Department of Human
Services, in cooperation with the Department on Aging, shall
implement an electronic service verification based on global
positioning systems or other cost-effective technology.
    (h) The Department shall not pay for hospital admissions
when the claim indicates a hospital acquired condition that
would cause Medicare to reduce its payment on the claim had the
claim been submitted to Medicare, nor shall the Department pay
for hospital admissions where a Medicare identified "never
event" occurred.
    (i) The Department shall implement cost savings
initiatives for advanced imaging services, cardiac imaging
services, pain management services, and back surgery. Such
initiatives shall be designed to achieve annual costs savings.
 
    (305 ILCS 5/5-16.7)
    Sec. 5-16.7. Post-parturition care. The medical assistance
program shall provide the post-parturition care benefits
required to be covered by a policy of accident and health
insurance under Section 356s of the Illinois Insurance Code.
    On and after July 1, 2012, the Department shall reduce any
rate of reimbursement for services or other payments or alter
any methodologies authorized by this Code to reduce any rate of
reimbursement for services or other payments in accordance with
Section 5-5e.
(Source: P.A. 89-513, eff. 9-15-96; 90-14, eff. 7-1-97.)
 
    (305 ILCS 5/5-16.7a)
    Sec. 5-16.7a. Reimbursement for epidural anesthesia
services. In addition to other procedures authorized by the
Department under this Code, the Department shall provide
reimbursement to medical providers for epidural anesthesia
services when ordered by the attending practitioner at the time
of delivery.
    On and after July 1, 2012, the Department shall reduce any
rate of reimbursement for services or other payments or alter
any methodologies authorized by this Code to reduce any rate of
reimbursement for services or other payments in accordance with
Section 5-5e.
(Source: P.A. 93-981, eff. 8-23-04.)
 
    (305 ILCS 5/5-16.8)
    Sec. 5-16.8. Required health benefits. The medical
assistance program shall (i) provide the post-mastectomy care
benefits required to be covered by a policy of accident and
health insurance under Section 356t and the coverage required
under Sections 356g.5, 356u, 356w, 356x, and 356z.6 of the
Illinois Insurance Code and (ii) be subject to the provisions
of Sections 356z.19 and 364.01 of the Illinois Insurance Code.
    On and after July 1, 2012, the Department shall reduce any
rate of reimbursement for services or other payments or alter
any methodologies authorized by this Code to reduce any rate of
reimbursement for services or other payments in accordance with
Section 5-5e.
(Source: P.A. 97-282, eff. 8-9-11.)
 
    (305 ILCS 5/5-16.9)
    Sec. 5-16.9. Woman's health care provider. The medical
assistance program is subject to the provisions of Section 356r
of the Illinois Insurance Code. The Illinois Department shall
adopt rules to implement the requirements of Section 356r of
the Illinois Insurance Code in the medical assistance program
including managed care components.
    On and after July 1, 2012, the Department shall reduce any
rate of reimbursement for services or other payments or alter
any methodologies authorized by this Code to reduce any rate of
reimbursement for services or other payments in accordance with
Section 5-5e.
(Source: P.A. 92-370, eff. 8-15-01.)
 
    (305 ILCS 5/5-17)  (from Ch. 23, par. 5-17)
    Sec. 5-17. Programs to improve access to hospital care.
    (a) (1) The General Assembly finds:
            (A) That while hospitals have traditionally
        provided charitable care to indigent patients, this
        burden is not equally borne by all hospitals operating
        in this State. Some hospitals continue to provide
        significant amounts of care to low-income persons
        while others provide very little such care; and
            (B) That access to hospital care in this State by
        the indigent citizens of Illinois would be seriously
        impaired by the closing of hospitals that provide
        significant amounts of care to low-income persons.
        (2) To help expand the availability of hospital care
    for all citizens of this State, it is the policy of the
    State to implement programs that more equitably distribute
    the burden of providing hospital care to Illinois'
    low-income population and that improve access to health
    care in Illinois.
        (3) The Illinois Department may develop and implement a
    program that lessens the burden of providing hospital care
    to Illinois' low-income population, taking into account
    the costs that must be incurred by hospitals providing
    significant amounts of care to low-income persons, and may
    develop adjustments to increase rates to improve access to
    health care in Illinois. The Illinois Department shall
    prescribe by rule the criteria, standards and procedures
    for effecting such adjustments in the rates of hospital
    payments for services provided to eligible low-income
    persons (under Articles V, VI and VII of this Code) under
    this Article.
    (b) The Illinois Department shall require hospitals
certified to participate in the federal Medicaid program to:
        (1) provide equal access to available services to
    low-income persons who are eligible for assistance under
    Articles V, VI and VII of this Code;
        (2) provide data and reports on the provision of
    uncompensated care.
    (c) From the effective date of this amendatory Act of 1992
until July 1, 1992, nothing in this Section 5-17 shall be
construed as creating a private right of action on behalf of
any individual.
    (d) On and after July 1, 2012, the Department shall reduce
any rate of reimbursement for services or other payments or
alter any methodologies authorized by this Code to reduce any
rate of reimbursement for services or other payments in
accordance with Section 5-5e.
(Source: P.A. 87-13; 87-838.)
 
    (305 ILCS 5/5-19)  (from Ch. 23, par. 5-19)
    Sec. 5-19. Healthy Kids Program.
    (a) Any child under the age of 21 eligible to receive
Medical Assistance from the Illinois Department under Article V
of this Code shall be eligible for Early and Periodic
Screening, Diagnosis and Treatment services provided by the
Healthy Kids Program of the Illinois Department under the
Social Security Act, 42 U.S.C. 1396d(r).
    (b) Enrollment of Children in Medicaid. The Illinois
Department shall provide for receipt and initial processing of
applications for Medical Assistance for all pregnant women and
children under the age of 21 at locations in addition to those
used for processing applications for cash assistance,
including disproportionate share hospitals, federally
qualified health centers and other sites as selected by the
Illinois Department.
    (c) Healthy Kids Examinations. The Illinois Department
shall consider any examination of a child eligible for the
Healthy Kids services provided by a medical provider meeting
the requirements and complying with the rules and regulations
of the Illinois Department to be reimbursed as a Healthy Kids
examination.
    (d) Medical Screening Examinations.
        (1) The Illinois Department shall insure Medicaid
    coverage for periodic health, vision, hearing, and dental
    screenings for children eligible for Healthy Kids services
    scheduled from a child's birth up until the child turns 21
    years. The Illinois Department shall pay for vision,
    hearing, dental and health screening examinations for any
    child eligible for Healthy Kids services by qualified
    providers at intervals established by Department rules.
        (2) The Illinois Department shall pay for an
    interperiodic health, vision, hearing, or dental screening
    examination for any child eligible for Healthy Kids
    services whenever an examination is:
            (A) requested by a child's parent, guardian, or
        custodian, or is determined to be necessary or
        appropriate by social services, developmental, health,
        or educational personnel; or
            (B) necessary for enrollment in school; or
            (C) necessary for enrollment in a licensed day care
        program, including Head Start; or
            (D) necessary for placement in a licensed child
        welfare facility, including a foster home, group home
        or child care institution; or
            (E) necessary for attendance at a camping program;
        or
            (F) necessary for participation in an organized
        athletic program; or
            (G) necessary for enrollment in an early childhood
        education program recognized by the Illinois State
        Board of Education; or
            (H) necessary for participation in a Women,
        Infant, and Children (WIC) program; or
            (I) deemed appropriate by the Illinois Department.
    (e) Minimum Screening Protocols For Periodic Health
Screening Examinations. Health Screening Examinations must
include the following services:
        (1) Comprehensive Health and Development Assessment
    including:
            (A) Development/Mental Health/Psychosocial
        Assessment; and
            (B) Assessment of nutritional status including
        tests for iron deficiency and anemia for children at
        the following ages: 9 months, 2 years, 8 years, and 18
        years;
        (2) Comprehensive unclothed physical exam;
        (3) Appropriate immunizations at a minimum, as
    required by the Secretary of the U.S. Department of Health
    and Human Services under 42 U.S.C. 1396d(r).
        (4) Appropriate laboratory tests including blood lead
    levels appropriate for age and risk factors.
            (A) Anemia test.
            (B) Sickle cell test.
            (C) Tuberculin test at 12 months of age and every
        1-2 years thereafter unless the treating health care
        professional determines that testing is medically
        contraindicated.
            (D) Other -- The Illinois Department shall insure
        that testing for HIV, drug exposure, and sexually
        transmitted diseases is provided for as clinically
        indicated.
        (5) Health Education. The Illinois Department shall
    require providers to provide anticipatory guidance as
    recommended by the American Academy of Pediatrics.
        (6) Vision Screening. The Illinois Department shall
    require providers to provide vision screenings consistent
    with those set forth in the Department of Public Health's
    Administrative Rules.
        (7) Hearing Screening. The Illinois Department shall
    require providers to provide hearing screenings consistent
    with those set forth in the Department of Public Health's
    Administrative Rules.
        (8) Dental Screening. The Illinois Department shall
    require providers to provide dental screenings consistent
    with those set forth in the Department of Public Health's
    Administrative Rules.
    (f) Covered Medical Services. The Illinois Department
shall provide coverage for all necessary health care,
diagnostic services, treatment and other measures to correct or
ameliorate defects, physical and mental illnesses, and
conditions whether discovered by the screening services or not
for all children eligible for Medical Assistance under Article
V of this Code.
    (g) Notice of Healthy Kids Services.
        (1) The Illinois Department shall inform any child
    eligible for Healthy Kids services and the child's family
    about the benefits provided under the Healthy Kids Program,
    including, but not limited to, the following: what services
    are available under Healthy Kids, including discussion of
    the periodicity schedules and immunization schedules, that
    services are provided at no cost to eligible children, the
    benefits of preventive health care, where the services are
    available, how to obtain them, and that necessary
    transportation and scheduling assistance is available.
        (2) The Illinois Department shall widely disseminate
    information regarding the availability of the Healthy Kids
    Program throughout the State by outreach activities which
    shall include, but not be limited to, (i) the development
    of cooperation agreements with local school districts,
    public health agencies, clinics, hospitals and other
    health care providers, including developmental disability
    and mental health providers, and with charities, to notify
    the constituents of each of the Program and assist
    individuals, as feasible, with applying for the Program,
    (ii) using the media for public service announcements and
    advertisements of the Program, and (iii) developing
    posters advertising the Program for display in hospital and
    clinic waiting rooms.
        (3) The Illinois Department shall utilize accepted
    methods for informing persons who are illiterate, blind,
    deaf, or cannot understand the English language, including
    but not limited to public services announcements and
    advertisements in the foreign language media of radio,
    television and newspapers.
        (4) The Illinois Department shall provide notice of the
    Healthy Kids Program to every child eligible for Healthy
    Kids services and his or her family at the following times:
            (A) orally by the intake worker and in writing at
        the time of application for Medical Assistance;
            (B) at the time the applicant is informed that he
        or she is eligible for Medical Assistance benefits; and
            (C) at least 20 days before the date of any
        periodic health, vision, hearing, and dental
        examination for any child eligible for Healthy Kids
        services. Notice given under this subparagraph (C)
        must state that a screening examination is due under
        the periodicity schedules and must advise the eligible
        child and his or her family that the Illinois
        Department will provide assistance in scheduling an
        appointment and arranging medical transportation.
    (h) Data Collection. The Illinois Department shall collect
data in a usable form to track utilization of Healthy Kids
screening examinations by children eligible for Healthy Kids
services, including but not limited to data showing screening
examinations and immunizations received, a summary of
follow-up treatment received by children eligible for Healthy
Kids services and the number of children receiving dental,
hearing and vision services.
    (i) On and after July 1, 2012, the Department shall reduce
any rate of reimbursement for services or other payments or
alter any methodologies authorized by this Code to reduce any
rate of reimbursement for services or other payments in
accordance with Section 5-5e.
(Source: P.A. 87-630; 87-895.)
 
    (305 ILCS 5/5-24)
    (Section scheduled to be repealed on January 1, 2014)
    Sec. 5-24. Disease management programs and services for
chronic conditions; pilot project.
    (a) In this Section, "disease management programs and
services" means services administered to patients in order to
improve their overall health and to prevent clinical
exacerbations and complications, using cost-effective,
evidence-based practice guidelines and patient self-management
strategies. Disease management programs and services include
all of the following:
        (1) A population identification process.
        (2) Evidence-based or consensus-based clinical
    practice guidelines, risk identification, and matching of
    interventions with clinical need.
        (3) Patient self-management and disease education.
        (4) Process and outcomes measurement, evaluation,
    management, and reporting.
    (b) Subject to appropriations, the Department of
Healthcare and Family Services may undertake a pilot project to
study patient outcomes, for patients with chronic diseases or
patients at risk of low birth weight or premature birth,
associated with the use of disease management programs and
services for chronic condition management. "Chronic diseases"
include, but are not limited to, diabetes, congestive heart
failure, and chronic obstructive pulmonary disease. Low birth
weight and premature birth include all medical and other
conditions that lead to poor birth outcomes or problematic
pregnancies.
    (c) The disease management programs and services pilot
project shall examine whether chronic disease management
programs and services for patients with specific chronic
conditions do any or all of the following:
        (1) Improve the patient's overall health in a more
    expeditious manner.
        (2) Lower costs in other aspects of the medical
    assistance program, such as hospital admissions, days in
    skilled nursing homes, emergency room visits, or more
    frequent physician office visits.
    (d) In carrying out the pilot project, the Department of
Healthcare and Family Services shall examine all relevant
scientific literature and shall consult with health care
practitioners including, but not limited to, physicians,
surgeons, registered pharmacists, and registered nurses.
    (e) The Department of Healthcare and Family Services shall
consult with medical experts, disease advocacy groups, and
academic institutions to develop criteria to be used in
selecting a vendor for the pilot project.
    (f) The Department of Healthcare and Family Services may
adopt rules to implement this Section.
    (g) This Section is repealed 10 years after the effective
date of this amendatory Act of the 93rd General Assembly.
    (h) On and after July 1, 2012, the Department shall reduce
any rate of reimbursement for services or other payments or
alter any methodologies authorized by this Code to reduce any
rate of reimbursement for services or other payments in
accordance with Section 5-5e.
(Source: P.A. 95-331, eff. 8-21-07; 96-799, eff. 10-28-09.)
 
    (305 ILCS 5/5-30)
    Sec. 5-30. Care coordination.
    (a) At least 50% of recipients eligible for comprehensive
medical benefits in all medical assistance programs or other
health benefit programs administered by the Department,
including the Children's Health Insurance Program Act and the
Covering ALL KIDS Health Insurance Act, shall be enrolled in a
care coordination program by no later than January 1, 2015. For
purposes of this Section, "coordinated care" or "care
coordination" means delivery systems where recipients will
receive their care from providers who participate under
contract in integrated delivery systems that are responsible
for providing or arranging the majority of care, including
primary care physician services, referrals from primary care
physicians, diagnostic and treatment services, behavioral
health services, in-patient and outpatient hospital services,
dental services, and rehabilitation and long-term care
services. The Department shall designate or contract for such
integrated delivery systems (i) to ensure enrollees have a
choice of systems and of primary care providers within such
systems; (ii) to ensure that enrollees receive quality care in
a culturally and linguistically appropriate manner; and (iii)
to ensure that coordinated care programs meet the diverse needs
of enrollees with developmental, mental health, physical, and
age-related disabilities.
    (b) Payment for such coordinated care shall be based on
arrangements where the State pays for performance related to
health care outcomes, the use of evidence-based practices, the
use of primary care delivered through comprehensive medical
homes, the use of electronic medical records, and the
appropriate exchange of health information electronically made
either on a capitated basis in which a fixed monthly premium
per recipient is paid and full financial risk is assumed for
the delivery of services, or through other risk-based payment
arrangements.
    (c) To qualify for compliance with this Section, the 50%
goal shall be achieved by enrolling medical assistance
enrollees from each medical assistance enrollment category,
including parents, children, seniors, and people with
disabilities to the extent that current State Medicaid payment
laws would not limit federal matching funds for recipients in
care coordination programs. In addition, services must be more
comprehensively defined and more risk shall be assumed than in
the Department's primary care case management program as of the
effective date of this amendatory Act of the 96th General
Assembly.
    (d) The Department shall report to the General Assembly in
a separate part of its annual medical assistance program
report, beginning April, 2012 until April, 2016, on the
progress and implementation of the care coordination program
initiatives established by the provisions of this amendatory
Act of the 96th General Assembly. The Department shall include
in its April 2011 report a full analysis of federal laws or
regulations regarding upper payment limitations to providers
and the necessary revisions or adjustments in rate
methodologies and payments to providers under this Code that
would be necessary to implement coordinated care with full
financial risk by a party other than the Department.
    (e) Integrated Care Program for individuals with chronic
mental health conditions.
        (1) The Integrated Care Program shall encompass
    services administered to recipients of medical assistance
    under this Article to prevent exacerbations and
    complications using cost-effective, evidence-based
    practice guidelines and mental health management
    strategies.
        (2) The Department may utilize and expand upon existing
    contractual arrangements with integrated care plans under
    the Integrated Care Program for providing the coordinated
    care provisions of this Section.
        (3) Payment for such coordinated care shall be based on
    arrangements where the State pays for performance related
    to mental health outcomes on a capitated basis in which a
    fixed monthly premium per recipient is paid and full
    financial risk is assumed for the delivery of services, or
    through other risk-based payment arrangements such as
    provider-based care coordination.
        (4) The Department shall examine whether chronic
    mental health management programs and services for
    recipients with specific chronic mental health conditions
    do any or all of the following:
            (A) Improve the patient's overall mental health in
        a more expeditious and cost-effective manner.
            (B) Lower costs in other aspects of the medical
        assistance program, such as hospital admissions,
        emergency room visits, or more frequent and
        inappropriate psychotropic drug use.
        (5) The Department shall work with the facilities and
    any integrated care plan participating in the program to
    identify and correct barriers to the successful
    implementation of this subsection (e) prior to and during
    the implementation to best facilitate the goals and
    objectives of this subsection (e).
    (f) A hospital that is located in a county of the State in
which the Department mandates some or all of the beneficiaries
of the Medical Assistance Program residing in the county to
enroll in a Care Coordination Program, as set forth in Section
5-30 of this Code, shall not be eligible for any non-claims
based payments not mandated by Article V-A of this Code for
which it would otherwise be qualified to receive, unless the
hospital is a Coordinated Care Participating Hospital no later
than 60 days after the effective date of this amendatory Act of
the 97th General Assembly or 60 days after the first mandatory
enrollment of a beneficiary in a Coordinated Care program. For
purposes of this subsection, "Coordinated Care Participating
Hospital" means a hospital that meets one of the following
criteria:
        (1) The hospital has entered into a contract to provide
    hospital services to enrollees of the care coordination
    program.
        (2) The hospital has not been offered a contract by a
    care coordination plan that pays at least as much as the
    Department would pay, on a fee-for-service basis, not
    including disproportionate share hospital adjustment
    payments or any other supplemental adjustment or add-on
    payment to the base fee-for-service rate.
(Source: P.A. 96-1501, eff. 1-25-11.)
 
    (305 ILCS 5/5A-1)  (from Ch. 23, par. 5A-1)
    Sec. 5A-1. Definitions. As used in this Article, unless
the context requires otherwise:
    "Adjusted gross hospital revenue" shall be determined
separately for inpatient and outpatient services for each
hospital conducted, operated or maintained by a hospital
provider, and means the hospital provider's total gross
revenues less: (i) gross revenue attributable to non-hospital
based services including home dialysis services, durable
medical equipment, ambulance services, outpatient clinics and
any other non-hospital based services as determined by the
Illinois Department by rule; and (ii) gross revenues
attributable to the routine services provided to persons
receiving skilled or intermediate long-term care services
within the meaning of Title XVIII or XIX of the Social Security
Act; and (iii) Medicare gross revenue (excluding the Medicare
gross revenue attributable to clauses (i) and (ii) of this
paragraph and the Medicare gross revenue attributable to the
routine services provided to patients in a psychiatric
hospital, a rehabilitation hospital, a distinct part
psychiatric unit, a distinct part rehabilitation unit, or swing
beds). Adjusted gross hospital revenue shall be determined
using the most recent data available from each hospital's 2003
Medicare cost report as contained in the Healthcare Cost Report
Information System file, for the quarter ending on December 31,
2004, without regard to any subsequent adjustments or changes
to such data. If a hospital's 2003 Medicare cost report is not
contained in the Healthcare Cost Report Information System, the
hospital provider shall furnish such cost report or the data
necessary to determine its adjusted gross hospital revenue as
required by rule by the Illinois Department.
    "Fund" means the Hospital Provider Fund.
    "Hospital" means an institution, place, building, or
agency located in this State that is subject to licensure by
the Illinois Department of Public Health under the Hospital
Licensing Act, whether public or private and whether organized
for profit or not-for-profit.
    "Hospital provider" means a person licensed by the
Department of Public Health to conduct, operate, or maintain a
hospital, regardless of whether the person is a Medicaid
provider. For purposes of this paragraph, "person" means any
political subdivision of the State, municipal corporation,
individual, firm, partnership, corporation, company, limited
liability company, association, joint stock association, or
trust, or a receiver, executor, trustee, guardian, or other
representative appointed by order of any court.
    "Medicare bed days" means, for each hospital, the sum of
the number of days that each bed was occupied by a patient who
was covered by Title XVIII of the Social Security Act,
excluding days attributable to the routine services provided to
persons receiving skilled or intermediate long term care
services. Medicare bed days shall be computed separately for
each hospital operated or maintained by a hospital provider.
    "Occupied bed days" means the sum of the number of days
that each bed was occupied by a patient for all beds, excluding
days attributable to the routine services provided to persons
receiving skilled or intermediate long term care services.
Occupied bed days shall be computed separately for each
hospital operated or maintained by a hospital provider.
    "Proration factor" means a fraction, the numerator of which
is 53 and the denominator of which is 365.
(Source: P.A. 94-242, eff. 7-18-05; 95-859, eff. 8-19-08.)
 
    (305 ILCS 5/5A-2)  (from Ch. 23, par. 5A-2)
    (Section scheduled to be repealed on July 1, 2014)
    Sec. 5A-2. Assessment.
    (a) Subject to Sections 5A-3 and 5A-10, an annual
assessment on inpatient services is imposed on each hospital
provider in an amount equal to the hospital's occupied bed days
multiplied by $84.19 multiplied by the proration factor for
State fiscal year 2004 and the hospital's occupied bed days
multiplied by $84.19 for State fiscal year 2005.
    For State fiscal years 2004 and 2005, the Department of
Healthcare and Family Services shall use the number of occupied
bed days as reported by each hospital on the Annual Survey of
Hospitals conducted by the Department of Public Health to
calculate the hospital's annual assessment. If the sum of a
hospital's occupied bed days is not reported on the Annual
Survey of Hospitals or if there are data errors in the reported
sum of a hospital's occupied bed days as determined by the
Department of Healthcare and Family Services (formerly
Department of Public Aid), then the Department of Healthcare
and Family Services may obtain the sum of occupied bed days
from any source available, including, but not limited to,
records maintained by the hospital provider, which may be
inspected at all times during business hours of the day by the
Department of Healthcare and Family Services or its duly
authorized agents and employees.
    Subject to Sections 5A-3 and 5A-10, for the privilege of
engaging in the occupation of hospital provider, beginning
August 1, 2005, an annual assessment is imposed on each
hospital provider for State fiscal years 2006, 2007, and 2008,
in an amount equal to 2.5835% of the hospital provider's
adjusted gross hospital revenue for inpatient services and
2.5835% of the hospital provider's adjusted gross hospital
revenue for outpatient services. If the hospital provider's
adjusted gross hospital revenue is not available, then the
Illinois Department may obtain the hospital provider's
adjusted gross hospital revenue from any source available,
including, but not limited to, records maintained by the
hospital provider, which may be inspected at all times during
business hours of the day by the Illinois Department or its
duly authorized agents and employees.
    Subject to Sections 5A-3 and 5A-10, for State fiscal years
2009 through 2014 and July 1, 2014 through December 31, 2014,
an annual assessment on inpatient services is imposed on each
hospital provider in an amount equal to $218.38 multiplied by
the difference of the hospital's occupied bed days less the
hospital's Medicare bed days.
    For State fiscal years 2009 through 2014 and after, a
hospital's occupied bed days and Medicare bed days shall be
determined using the most recent data available from each
hospital's 2005 Medicare cost report as contained in the
Healthcare Cost Report Information System file, for the quarter
ending on December 31, 2006, without regard to any subsequent
adjustments or changes to such data. If a hospital's 2005
Medicare cost report is not contained in the Healthcare Cost
Report Information System, then the Illinois Department may
obtain the hospital provider's occupied bed days and Medicare
bed days from any source available, including, but not limited
to, records maintained by the hospital provider, which may be
inspected at all times during business hours of the day by the
Illinois Department or its duly authorized agents and
employees.
    (b) (Blank).
    (c) (Blank).
    (d) Notwithstanding any of the other provisions of this
Section, the Department is authorized, during this 94th General
Assembly, to adopt rules to reduce the rate of any annual
assessment imposed under this Section, as authorized by Section
5-46.2 of the Illinois Administrative Procedure Act.
    (e) Notwithstanding any other provision of this Section,
any plan providing for an assessment on a hospital provider as
a permissible tax under Title XIX of the federal Social
Security Act and Medicaid-eligible payments to hospital
providers from the revenues derived from that assessment shall
be reviewed by the Illinois Department of Healthcare and Family
Services, as the Single State Medicaid Agency required by
federal law, to determine whether those assessments and
hospital provider payments meet federal Medicaid standards. If
the Department determines that the elements of the plan may
meet federal Medicaid standards and a related State Medicaid
Plan Amendment is prepared in a manner and form suitable for
submission, that State Plan Amendment shall be submitted in a
timely manner for review by the Centers for Medicare and
Medicaid Services of the United States Department of Health and
Human Services and subject to approval by the Centers for
Medicare and Medicaid Services of the United States Department
of Health and Human Services. No such plan shall become
effective without approval by the Illinois General Assembly by
the enactment into law of related legislation. Notwithstanding
any other provision of this Section, the Department is
authorized to adopt rules to reduce the rate of any annual
assessment imposed under this Section. Any such rules may be
adopted by the Department under Section 5-50 of the Illinois
Administrative Procedure Act.
(Source: P.A. 95-859, eff. 8-19-08; 96-1530, eff. 2-16-11.)
 
    (305 ILCS 5/5A-3)  (from Ch. 23, par. 5A-3)
    Sec. 5A-3. Exemptions.
    (a) (Blank).
    (b) A hospital provider that is a State agency, a State
university, or a county with a population of 3,000,000 or more
is exempt from the assessment imposed by Section 5A-2.
    (b-2) A hospital provider that is a county with a
population of less than 3,000,000 or a township, municipality,
hospital district, or any other local governmental unit is
exempt from the assessment imposed by Section 5A-2.
    (b-5) (Blank).
    (b-10) (Blank). For State fiscal years 2004 through 2014, a
hospital provider, described in Section 1903(w)(3)(F) of the
Social Security Act, whose hospital does not charge for its
services is exempt from the assessment imposed by Section 5A-2,
unless the exemption is adjudged to be unconstitutional or
otherwise invalid, in which case the hospital provider shall
pay the assessment imposed by Section 5A-2.
    (b-15) (Blank). For State fiscal years 2004 and 2005, a
hospital provider whose hospital is licensed by the Department
of Public Health as a psychiatric hospital is exempt from the
assessment imposed by Section 5A-2, unless the exemption is
adjudged to be unconstitutional or otherwise invalid, in which
case the hospital provider shall pay the assessment imposed by
Section 5A-2.
    (b-20) (Blank). For State fiscal years 2004 and 2005, a
hospital provider whose hospital is licensed by the Department
of Public Health as a rehabilitation hospital is exempt from
the assessment imposed by Section 5A-2, unless the exemption is
adjudged to be unconstitutional or otherwise invalid, in which
case the hospital provider shall pay the assessment imposed by
Section 5A-2.
    (b-25) (Blank). For State fiscal years 2004 and 2005, a
hospital provider whose hospital (i) is not a psychiatric
hospital, rehabilitation hospital, or children's hospital and
(ii) has an average length of inpatient stay greater than 25
days is exempt from the assessment imposed by Section 5A-2,
unless the exemption is adjudged to be unconstitutional or
otherwise invalid, in which case the hospital provider shall
pay the assessment imposed by Section 5A-2.
    (c) (Blank).
(Source: P.A. 95-859, eff. 8-19-08; 96-1530, eff. 2-16-11.)
 
    (305 ILCS 5/5A-4)  (from Ch. 23, par. 5A-4)
    Sec. 5A-4. Payment of assessment; penalty.
    (a) The The annual assessment imposed by Section 5A-2 for
State fiscal year 2004 shall be due and payable on June 18 of
the year. The assessment imposed by Section 5A-2 for State
fiscal year 2005 shall be due and payable in quarterly
installments, each equalling one-fourth of the assessment for
the year, on July 19, October 19, January 18, and April 19 of
the year. The assessment imposed by Section 5A-2 for State
fiscal years 2006 through 2008 shall be due and payable in
quarterly installments, each equaling one-fourth of the
assessment for the year, on the fourteenth State business day
of September, December, March, and May. Except as provided in
subsection (a-5) of this Section, the assessment imposed by
Section 5A-2 for State fiscal year 2009 and each subsequent
State fiscal year shall be due and payable in monthly
installments, each equaling one-twelfth of the assessment for
the year, on the fourteenth State business day of each month.
No installment payment of an assessment imposed by Section 5A-2
shall be due and payable, however, until after the Comptroller
has issued the payments required under this Article. : (i) the
Department notifies the hospital provider, in writing, that the
payment methodologies to hospitals required under Section
5A-12, Section 5A-12.1, or Section 5A-12.2, whichever is
applicable for that fiscal year, have been approved by the
Centers for Medicare and Medicaid Services of the U.S.
Department of Health and Human Services and the waiver under 42
CFR 433.68 for the assessment imposed by Section 5A-2, if
necessary, has been granted by the Centers for Medicare and
Medicaid Services of the U.S. Department of Health and Human
Services; and (ii) the Comptroller has issued the payments
required under Section 5A-12, Section 5A-12.1, or Section
5A-12.2, whichever is applicable for that fiscal year. Upon
notification to the Department of approval of the payment
methodologies required under Section 5A-12, Section 5A-12.1,
or Section 5A-12.2, whichever is applicable for that fiscal
year, and the waiver granted under 42 CFR 433.68, all
installments otherwise due under Section 5A-2 prior to the date
of notification shall be due and payable to the Department upon
written direction from the Department and issuance by the
Comptroller of the payments required under Section 5A-12.1 or
Section 5A-12.2, whichever is applicable for that fiscal year.
    (a-5) The Illinois Department may, for the purpose of
maximizing federal revenue, accelerate the schedule upon which
assessment installments are due and payable by hospitals with a
payment ratio greater than or equal to one. Such acceleration
of due dates for payment of the assessment may be made only in
conjunction with a corresponding acceleration in access
payments identified in Section 5A-12.2 to the same hospitals.
For the purposes of this subsection (a-5), a hospital's payment
ratio is defined as the quotient obtained by dividing the total
payments for the State fiscal year, as authorized under Section
5A-12.2, by the total assessment for the State fiscal year
imposed under Section 5A-2.
    (b) The Illinois Department is authorized to establish
delayed payment schedules for hospital providers that are
unable to make installment payments when due under this Section
due to financial difficulties, as determined by the Illinois
Department.
    (c) If a hospital provider fails to pay the full amount of
an installment when due (including any extensions granted under
subsection (b)), there shall, unless waived by the Illinois
Department for reasonable cause, be added to the assessment
imposed by Section 5A-2 a penalty assessment equal to the
lesser of (i) 5% of the amount of the installment not paid on
or before the due date plus 5% of the portion thereof remaining
unpaid on the last day of each 30-day period thereafter or (ii)
100% of the installment amount not paid on or before the due
date. For purposes of this subsection, payments will be
credited first to unpaid installment amounts (rather than to
penalty or interest), beginning with the most delinquent
installments.
    (d) Any assessment amount that is due and payable to the
Illinois Department more frequently than once per calendar
quarter shall be remitted to the Illinois Department by the
hospital provider by means of electronic funds transfer. The
Illinois Department may provide for remittance by other means
if (i) the amount due is less than $10,000 or (ii) electronic
funds transfer is unavailable for this purpose.
(Source: P.A. 95-331, eff. 8-21-07; 95-859, eff. 8-19-08;
96-821, eff. 11-20-09.)
 
    (305 ILCS 5/5A-5)  (from Ch. 23, par. 5A-5)
    Sec. 5A-5. Notice; penalty; maintenance of records.
    (a) The Illinois Department of Healthcare and Family
Services shall send a notice of assessment to every hospital
provider subject to assessment under this Article. The notice
of assessment shall notify the hospital of its assessment and
shall be sent after receipt by the Department of notification
from the Centers for Medicare and Medicaid Services of the U.S.
Department of Health and Human Services that the payment
methodologies required under this Article Section 5A-12,
Section 5A-12.1, or Section 5A-12.2, whichever is applicable
for that fiscal year, and, if necessary, the waiver granted
under 42 CFR 433.68 have been approved. The notice shall be on
a form prepared by the Illinois Department and shall state the
following:
        (1) The name of the hospital provider.
        (2) The address of the hospital provider's principal
    place of business from which the provider engages in the
    occupation of hospital provider in this State, and the name
    and address of each hospital operated, conducted, or
    maintained by the provider in this State.
        (3) The occupied bed days, occupied bed days less
    Medicare days, or adjusted gross hospital revenue of the
    hospital provider (whichever is applicable), the amount of
    assessment imposed under Section 5A-2 for the State fiscal
    year for which the notice is sent, and the amount of each
    installment to be paid during the State fiscal year.
        (4) (Blank).
        (5) Other reasonable information as determined by the
    Illinois Department.
    (b) If a hospital provider conducts, operates, or maintains
more than one hospital licensed by the Illinois Department of
Public Health, the provider shall pay the assessment for each
hospital separately.
    (c) Notwithstanding any other provision in this Article, in
the case of a person who ceases to conduct, operate, or
maintain a hospital in respect of which the person is subject
to assessment under this Article as a hospital provider, the
assessment for the State fiscal year in which the cessation
occurs shall be adjusted by multiplying the assessment computed
under Section 5A-2 by a fraction, the numerator of which is the
number of days in the year during which the provider conducts,
operates, or maintains the hospital and the denominator of
which is 365. Immediately upon ceasing to conduct, operate, or
maintain a hospital, the person shall pay the assessment for
the year as so adjusted (to the extent not previously paid).
    (d) Notwithstanding any other provision in this Article, a
provider who commences conducting, operating, or maintaining a
hospital, upon notice by the Illinois Department, shall pay the
assessment computed under Section 5A-2 and subsection (e) in
installments on the due dates stated in the notice and on the
regular installment due dates for the State fiscal year
occurring after the due dates of the initial notice.
    (e) Notwithstanding any other provision in this Article,
for State fiscal years 2004 and 2005, in the case of a hospital
provider that did not conduct, operate, or maintain a hospital
throughout calendar year 2001, the assessment for that State
fiscal year shall be computed on the basis of hypothetical
occupied bed days for the full calendar year as determined by
the Illinois Department. Notwithstanding any other provision
in this Article, for State fiscal years 2006 through 2008, in
the case of a hospital provider that did not conduct, operate,
or maintain a hospital in 2003, the assessment for that State
fiscal year shall be computed on the basis of hypothetical
adjusted gross hospital revenue for the hospital's first full
fiscal year as determined by the Illinois Department (which may
be based on annualization of the provider's actual revenues for
a portion of the year, or revenues of a comparable hospital for
the year, including revenues realized by a prior provider of
the same hospital during the year). Notwithstanding any other
provision in this Article, for State fiscal years 2009 through
2015 2014, in the case of a hospital provider that did not
conduct, operate, or maintain a hospital in 2005, the
assessment for that State fiscal year shall be computed on the
basis of hypothetical occupied bed days for the full calendar
year as determined by the Illinois Department.
    (f) Every hospital provider subject to assessment under
this Article shall keep sufficient records to permit the
determination of adjusted gross hospital revenue for the
hospital's fiscal year. All such records shall be kept in the
English language and shall, at all times during regular
business hours of the day, be subject to inspection by the
Illinois Department or its duly authorized agents and
employees.
    (g) The Illinois Department may, by rule, provide a
hospital provider a reasonable opportunity to request a
clarification or correction of any clerical or computational
errors contained in the calculation of its assessment, but such
corrections shall not extend to updating the cost report
information used to calculate the assessment.
    (h) (Blank).
(Source: P.A. 95-331, eff. 8-21-07; 95-859, eff. 8-19-08;
96-1530, eff. 2-16-11.)
 
    (305 ILCS 5/5A-6)  (from Ch. 23, par. 5A-6)
    Sec. 5A-6. Disposition of proceeds. The Illinois
Department shall deposit pay all moneys received from hospital
providers under this Article into the Hospital Provider Fund.
Upon certification by the Illinois Department to the State
Comptroller of its intent to withhold payments from a provider
pursuant to under Section 5A-7(b), the State Comptroller shall
draw a warrant on the treasury or other fund held by the State
Treasurer, as appropriate. The warrant shall state the amount
for which the provider is entitled to a warrant, the amount of
the deduction, and the reason therefor and shall direct the
State Treasurer to pay the balance to the provider, all in
accordance with Section 10.05 of the State Comptroller Act. The
warrant also shall direct the State Treasurer to transfer the
amount of the deduction so ordered from the treasury or other
fund into the Hospital Provider Fund.
(Source: P.A. 87-861.)
 
    (305 ILCS 5/5A-8)  (from Ch. 23, par. 5A-8)
    Sec. 5A-8. Hospital Provider Fund.
    (a) There is created in the State Treasury the Hospital
Provider Fund. Interest earned by the Fund shall be credited to
the Fund. The Fund shall not be used to replace any moneys
appropriated to the Medicaid program by the General Assembly.
    (b) The Fund is created for the purpose of receiving moneys
in accordance with Section 5A-6 and disbursing moneys only for
the following purposes, notwithstanding any other provision of
law:
        (1) For making payments to hospitals as required under
    Articles V, V-A, VI, and XIV of this Code, under the
    Children's Health Insurance Program Act, under the
    Covering ALL KIDS Health Insurance Act, and under the Long
    Term Acute Care Hospital Quality Improvement Transfer
    Program Act. Senior Citizens and Disabled Persons Property
    Tax Relief and Pharmaceutical Assistance Act.
        (2) For the reimbursement of moneys collected by the
    Illinois Department from hospitals or hospital providers
    through error or mistake in performing the activities
    authorized under this Article and Article V of this Code.
        (3) For payment of administrative expenses incurred by
    the Illinois Department or its agent in performing the
    activities under authorized by this Code, the Children's
    Health Insurance Program Act, the Covering ALL KIDS Health
    Insurance Act, and the Long Term Acute Care Hospital
    Quality Improvement Transfer Program Act. Article.
        (4) For payments of any amounts which are reimbursable
    to the federal government for payments from this Fund which
    are required to be paid by State warrant.
        (5) For making transfers, as those transfers are
    authorized in the proceedings authorizing debt under the
    Short Term Borrowing Act, but transfers made under this
    paragraph (5) shall not exceed the principal amount of debt
    issued in anticipation of the receipt by the State of
    moneys to be deposited into the Fund.
        (6) For making transfers to any other fund in the State
    treasury, but transfers made under this paragraph (6) shall
    not exceed the amount transferred previously from that
    other fund into the Hospital Provider Fund plus any
    interest that would have been earned by that fund on the
    monies that had been transferred.
        (6.5) For making transfers to the Healthcare Provider
    Relief Fund, except that transfers made under this
    paragraph (6.5) shall not exceed $60,000,000 in the
    aggregate.
        (7) For making transfers not exceeding the following
    amounts, in each State fiscal year during which an
    assessment is imposed pursuant to Section 5A-2, to the
    following designated funds:
            Health and Human Services Medicaid Trust
                Fund..............................$20,000,000
            Long-Term Care Provider Fund..........$30,000,000
            General Revenue Fund.................$80,000,000.
    Transfers under this paragraph shall be made within 7 days
after the payments have been received pursuant to the schedule
of payments provided in subsection (a) of Section 5A-4. For
State fiscal years 2004 and 2005 for making transfers to the
Health and Human Services Medicaid Trust Fund, including 20% of
the moneys received from hospital providers under Section 5A-4
and transferred into the Hospital Provider Fund under Section
5A-6. For State fiscal year 2006 for making transfers to the
Health and Human Services Medicaid Trust Fund of up to
$130,000,000 per year of the moneys received from hospital
providers under Section 5A-4 and transferred into the Hospital
Provider Fund under Section 5A-6. Transfers under this
paragraph shall be made within 7 days after the payments have
been received pursuant to the schedule of payments provided in
subsection (a) of Section 5A-4.
        (7.5) (Blank). For State fiscal year 2007 for making
    transfers of the moneys received from hospital providers
    under Section 5A-4 and transferred into the Hospital
    Provider Fund under Section 5A-6 to the designated funds
    not exceeding the following amounts in that State fiscal
    year:
        Health and Human Services
            Medicaid Trust Fund.............................. $20,000,000
        Long-Term Care Provider Fund............ $30,000,000
        General Revenue Fund................... $80,000,000.
        Transfers under this paragraph shall be made within 7
    days after the payments have been received pursuant to the
    schedule of payments provided in subsection (a) of Section
    5A-4.
        (7.8) (Blank). For State fiscal year 2008, for making
    transfers of the moneys received from hospital providers
    under Section 5A-4 and transferred into the Hospital
    Provider Fund under Section 5A-6 to the designated funds
    not exceeding the following amounts in that State fiscal
    year:
        Health and Human Services
            Medicaid Trust Fund..................$40,000,000
        Long-Term Care Provider Fund..............$60,000,000
        General Revenue Fund....................$160,000,000.
        Transfers under this paragraph shall be made within 7
    days after the payments have been received pursuant to the
    schedule of payments provided in subsection (a) of Section
    5A-4.
        (7.9) (Blank). For State fiscal years 2009 through
    2014, for making transfers of the moneys received from
    hospital providers under Section 5A-4 and transferred into
    the Hospital Provider Fund under Section 5A-6 to the
    designated funds not exceeding the following amounts in
    that State fiscal year:
        Health and Human Services
            Medicaid Trust Fund...................$20,000,000
        Long Term Care Provider Fund..............$30,000,000
        General Revenue Fund.....................$80,000,000.
        Except as provided under this paragraph, transfers
    under this paragraph shall be made within 7 business days
    after the payments have been received pursuant to the
    schedule of payments provided in subsection (a) of Section
    5A-4. For State fiscal year 2009, transfers to the General
    Revenue Fund under this paragraph shall be made on or
    before June 30, 2009, as sufficient funds become available
    in the Hospital Provider Fund to both make the transfers
    and continue hospital payments.
        (8) For making refunds to hospital providers pursuant
    to Section 5A-10.
    Disbursements from the Fund, other than transfers
authorized under paragraphs (5) and (6) of this subsection,
shall be by warrants drawn by the State Comptroller upon
receipt of vouchers duly executed and certified by the Illinois
Department.
    (c) The Fund shall consist of the following:
        (1) All moneys collected or received by the Illinois
    Department from the hospital provider assessment imposed
    by this Article.
        (2) All federal matching funds received by the Illinois
    Department as a result of expenditures made by the Illinois
    Department that are attributable to moneys deposited in the
    Fund.
        (3) Any interest or penalty levied in conjunction with
    the administration of this Article.
        (4) Moneys transferred from another fund in the State
    treasury.
        (5) All other moneys received for the Fund from any
    other source, including interest earned thereon.
    (d) (Blank).
(Source: P.A. 95-707, eff. 1-11-08; 95-859, eff. 8-19-08; 96-3,
eff. 2-27-09; 96-45, eff. 7-15-09; 96-821, eff. 11-20-09;
96-1530, eff. 2-16-11.)
 
    (305 ILCS 5/5A-10)  (from Ch. 23, par. 5A-10)
    Sec. 5A-10. Applicability.
    (a) The assessment imposed by Section 5A-2 shall not take
effect or shall cease to be imposed and the Department's
obligation to make payments shall immediately cease, and any
moneys remaining in the Fund shall be refunded to hospital
providers in proportion to the amounts paid by them, if:
        (1) The payments to hospitals required under this
    Article are not eligible for federal matching funds under
    Title XIX or XXI of the Social Security Act The sum of the
    appropriations for State fiscal years 2004 and 2005 from
    the General Revenue Fund for hospital payments under the
    medical assistance program is less than $4,500,000,000 or
    the appropriation for each of State fiscal years 2006, 2007
    and 2008 from the General Revenue Fund for hospital
    payments under the medical assistance program is less than
    $2,500,000,000 increased annually to reflect any increase
    in the number of recipients, or the annual appropriation
    for State fiscal years 2009, 2010, 2011, 2013, and 2014,
    from the General Revenue Fund combined with the Hospital
    Provider Fund as authorized in Section 5A-8 for hospital
    payments under the medical assistance program, is less than
    the amount appropriated for State fiscal year 2009,
    adjusted annually to reflect any change in the number of
    recipients, excluding State fiscal year 2009 supplemental
    appropriations made necessary by the enactment of the
    American Recovery and Reinvestment Act of 2009; or
        (2) For State fiscal years prior to State fiscal year
    2009, the Department of Healthcare and Family Services
    (formerly Department of Public Aid) makes changes in its
    rules that reduce the hospital inpatient or outpatient
    payment rates, including adjustment payment rates, in
    effect on October 1, 2004, except for hospitals described
    in subsection (b) of Section 5A-3 and except for changes in
    the methodology for calculating outlier payments to
    hospitals for exceptionally costly stays, so long as those
    changes do not reduce aggregate expenditures below the
    amount expended in State fiscal year 2005 for such
    services; or
        (2) (2.1) For State fiscal years 2009 through 2014 and
    July 1, 2014 through December 31, 2014, the Department of
    Healthcare and Family Services adopts any administrative
    rule change to reduce payment rates or alters any payment
    methodology that reduces any payment rates made to
    operating hospitals under the approved Title XIX or Title
    XXI State plan in effect January 1, 2008 except for:
            (A) any changes for hospitals described in
        subsection (b) of Section 5A-3; or
            (B) any rates for payments made under this Article
        V-A; or
            (C) any changes proposed in State plan amendment
        transmittal numbers 08-01, 08-02, 08-04, 08-06, and
        08-07; or
            (D) in relation to any admissions on or after
        January 1, 2011, a modification in the methodology for
        calculating outlier payments to hospitals for
        exceptionally costly stays, for hospitals reimbursed
        under the diagnosis-related grouping methodology in
        effect on January 1, 2011; provided that the Department
        shall be limited to one such modification during the
        36-month period after the effective date of this
        amendatory Act of the 96th General Assembly; or
            (E) any changes affecting hospitals authorized by
        this amendatory Act of the 97th General Assembly.
        (3) The payments to hospitals required under Section
    5A-12 or Section 5A-12.2 are changed or are not eligible
    for federal matching funds under Title XIX or XXI of the
    Social Security Act.
    (b) The assessment imposed by Section 5A-2 shall not take
effect or shall cease to be imposed and the Department's
obligation to make payments shall immediately cease if the
assessment is determined to be an impermissible tax under Title
XIX of the Social Security Act. Moneys in the Hospital Provider
Fund derived from assessments imposed prior thereto shall be
disbursed in accordance with Section 5A-8 to the extent federal
financial participation is not reduced due to the
impermissibility of the assessments, and any remaining moneys
shall be refunded to hospital providers in proportion to the
amounts paid by them.
(Source: P.A. 96-8, eff. 4-28-09; 96-1530, eff. 2-16-11; 97-72,
eff. 7-1-11; 97-74, eff. 6-30-11.)
 
    (305 ILCS 5/5A-12.2)
    (Section scheduled to be repealed on July 1, 2014)
    Sec. 5A-12.2. Hospital access payments on or after July 1,
2008.
    (a) To preserve and improve access to hospital services,
for hospital services rendered on or after July 1, 2008, the
Illinois Department shall, except for hospitals described in
subsection (b) of Section 5A-3, make payments to hospitals as
set forth in this Section. These payments shall be paid in 12
equal installments on or before the seventh State business day
of each month, except that no payment shall be due within 100
days after the later of the date of notification of federal
approval of the payment methodologies required under this
Section or any waiver required under 42 CFR 433.68, at which
time the sum of amounts required under this Section prior to
the date of notification is due and payable. Payments under
this Section are not due and payable, however, until (i) the
methodologies described in this Section are approved by the
federal government in an appropriate State Plan amendment and
(ii) the assessment imposed under this Article is determined to
be a permissible tax under Title XIX of the Social Security
Act.
    (a-5) The Illinois Department may, when practicable,
accelerate the schedule upon which payments authorized under
this Section are made.
    (b) Across-the-board inpatient adjustment.
        (1) In addition to rates paid for inpatient hospital
    services, the Department shall pay to each Illinois general
    acute care hospital an amount equal to 40% of the total
    base inpatient payments paid to the hospital for services
    provided in State fiscal year 2005.
        (2) In addition to rates paid for inpatient hospital
    services, the Department shall pay to each freestanding
    Illinois specialty care hospital as defined in 89 Ill. Adm.
    Code 149.50(c)(1), (2), or (4) an amount equal to 60% of
    the total base inpatient payments paid to the hospital for
    services provided in State fiscal year 2005.
        (3) In addition to rates paid for inpatient hospital
    services, the Department shall pay to each freestanding
    Illinois rehabilitation or psychiatric hospital an amount
    equal to $1,000 per Medicaid inpatient day multiplied by
    the increase in the hospital's Medicaid inpatient
    utilization ratio (determined using the positive
    percentage change from the rate year 2005 Medicaid
    inpatient utilization ratio to the rate year 2007 Medicaid
    inpatient utilization ratio, as calculated by the
    Department for the disproportionate share determination).
        (4) In addition to rates paid for inpatient hospital
    services, the Department shall pay to each Illinois
    children's hospital an amount equal to 20% of the total
    base inpatient payments paid to the hospital for services
    provided in State fiscal year 2005 and an additional amount
    equal to 20% of the base inpatient payments paid to the
    hospital for psychiatric services provided in State fiscal
    year 2005.
        (5) In addition to rates paid for inpatient hospital
    services, the Department shall pay to each Illinois
    hospital eligible for a pediatric inpatient adjustment
    payment under 89 Ill. Adm. Code 148.298, as in effect for
    State fiscal year 2007, a supplemental pediatric inpatient
    adjustment payment equal to:
            (i) For freestanding children's hospitals as
        defined in 89 Ill. Adm. Code 149.50(c)(3)(A), 2.5
        multiplied by the hospital's pediatric inpatient
        adjustment payment required under 89 Ill. Adm. Code
        148.298, as in effect for State fiscal year 2008.
            (ii) For hospitals other than freestanding
        children's hospitals as defined in 89 Ill. Adm. Code
        149.50(c)(3)(B), 1.0 multiplied by the hospital's
        pediatric inpatient adjustment payment required under
        89 Ill. Adm. Code 148.298, as in effect for State
        fiscal year 2008.
    (c) Outpatient adjustment.
        (1) In addition to the rates paid for outpatient
    hospital services, the Department shall pay each Illinois
    hospital an amount equal to 2.2 multiplied by the
    hospital's ambulatory procedure listing payments for
    categories 1, 2, 3, and 4, as defined in 89 Ill. Adm. Code
    148.140(b), for State fiscal year 2005.
        (2) In addition to the rates paid for outpatient
    hospital services, the Department shall pay each Illinois
    freestanding psychiatric hospital an amount equal to 3.25
    multiplied by the hospital's ambulatory procedure listing
    payments for category 5b, as defined in 89 Ill. Adm. Code
    148.140(b)(1)(E), for State fiscal year 2005.
    (d) Medicaid high volume adjustment. In addition to rates
paid for inpatient hospital services, the Department shall pay
to each Illinois general acute care hospital that provided more
than 20,500 Medicaid inpatient days of care in State fiscal
year 2005 amounts as follows:
        (1) For hospitals with a case mix index equal to or
    greater than the 85th percentile of hospital case mix
    indices, $350 for each Medicaid inpatient day of care
    provided during that period; and
        (2) For hospitals with a case mix index less than the
    85th percentile of hospital case mix indices, $100 for each
    Medicaid inpatient day of care provided during that period.
    (e) Capital adjustment. In addition to rates paid for
inpatient hospital services, the Department shall pay an
additional payment to each Illinois general acute care hospital
that has a Medicaid inpatient utilization rate of at least 10%
(as calculated by the Department for the rate year 2007
disproportionate share determination) amounts as follows:
        (1) For each Illinois general acute care hospital that
    has a Medicaid inpatient utilization rate of at least 10%
    and less than 36.94% and whose capital cost is less than
    the 60th percentile of the capital costs of all Illinois
    hospitals, the amount of such payment shall equal the
    hospital's Medicaid inpatient days multiplied by the
    difference between the capital costs at the 60th percentile
    of the capital costs of all Illinois hospitals and the
    hospital's capital costs.
        (2) For each Illinois general acute care hospital that
    has a Medicaid inpatient utilization rate of at least
    36.94% and whose capital cost is less than the 75th
    percentile of the capital costs of all Illinois hospitals,
    the amount of such payment shall equal the hospital's
    Medicaid inpatient days multiplied by the difference
    between the capital costs at the 75th percentile of the
    capital costs of all Illinois hospitals and the hospital's
    capital costs.
    (f) Obstetrical care adjustment.
        (1) In addition to rates paid for inpatient hospital
    services, the Department shall pay $1,500 for each Medicaid
    obstetrical day of care provided in State fiscal year 2005
    by each Illinois rural hospital that had a Medicaid
    obstetrical percentage (Medicaid obstetrical days divided
    by Medicaid inpatient days) greater than 15% for State
    fiscal year 2005.
        (2) In addition to rates paid for inpatient hospital
    services, the Department shall pay $1,350 for each Medicaid
    obstetrical day of care provided in State fiscal year 2005
    by each Illinois general acute care hospital that was
    designated a level III perinatal center as of December 31,
    2006, and that had a case mix index equal to or greater
    than the 45th percentile of the case mix indices for all
    level III perinatal centers.
        (3) In addition to rates paid for inpatient hospital
    services, the Department shall pay $900 for each Medicaid
    obstetrical day of care provided in State fiscal year 2005
    by each Illinois general acute care hospital that was
    designated a level II or II+ perinatal center as of
    December 31, 2006, and that had a case mix index equal to
    or greater than the 35th percentile of the case mix indices
    for all level II and II+ perinatal centers.
    (g) Trauma adjustment.
        (1) In addition to rates paid for inpatient hospital
    services, the Department shall pay each Illinois general
    acute care hospital designated as a trauma center as of
    July 1, 2007, a payment equal to 3.75 multiplied by the
    hospital's State fiscal year 2005 Medicaid capital
    payments.
        (2) In addition to rates paid for inpatient hospital
    services, the Department shall pay $400 for each Medicaid
    acute inpatient day of care provided in State fiscal year
    2005 by each Illinois general acute care hospital that was
    designated a level II trauma center, as defined in 89 Ill.
    Adm. Code 148.295(a)(3) and 148.295(a)(4), as of July 1,
    2007.
        (3) In addition to rates paid for inpatient hospital
    services, the Department shall pay $235 for each Illinois
    Medicaid acute inpatient day of care provided in State
    fiscal year 2005 by each level I pediatric trauma center
    located outside of Illinois that had more than 8,000
    Illinois Medicaid inpatient days in State fiscal year 2005.
    (h) Supplemental tertiary care adjustment. In addition to
rates paid for inpatient services, the Department shall pay to
each Illinois hospital eligible for tertiary care adjustment
payments under 89 Ill. Adm. Code 148.296, as in effect for
State fiscal year 2007, a supplemental tertiary care adjustment
payment equal to the tertiary care adjustment payment required
under 89 Ill. Adm. Code 148.296, as in effect for State fiscal
year 2007.
    (i) Crossover adjustment. In addition to rates paid for
inpatient services, the Department shall pay each Illinois
general acute care hospital that had a ratio of crossover days
to total inpatient days for medical assistance programs
administered by the Department (utilizing information from
2005 paid claims) greater than 50%, and a case mix index
greater than the 65th percentile of case mix indices for all
Illinois hospitals, a rate of $1,125 for each Medicaid
inpatient day including crossover days.
    (j) Magnet hospital adjustment. In addition to rates paid
for inpatient hospital services, the Department shall pay to
each Illinois general acute care hospital and each Illinois
freestanding children's hospital that, as of February 1, 2008,
was recognized as a Magnet hospital by the American Nurses
Credentialing Center and that had a case mix index greater than
the 75th percentile of case mix indices for all Illinois
hospitals amounts as follows:
        (1) For hospitals located in a county whose eligibility
    growth factor is greater than the mean, $450 multiplied by
    the eligibility growth factor for the county in which the
    hospital is located for each Medicaid inpatient day of care
    provided by the hospital during State fiscal year 2005.
        (2) For hospitals located in a county whose eligibility
    growth factor is less than or equal to the mean, $225
    multiplied by the eligibility growth factor for the county
    in which the hospital is located for each Medicaid
    inpatient day of care provided by the hospital during State
    fiscal year 2005.
    For purposes of this subsection, "eligibility growth
factor" means the percentage by which the number of Medicaid
recipients in the county increased from State fiscal year 1998
to State fiscal year 2005.
    (k) For purposes of this Section, a hospital that is
enrolled to provide Medicaid services during State fiscal year
2005 shall have its utilization and associated reimbursements
annualized prior to the payment calculations being performed
under this Section.
    (l) For purposes of this Section, the terms "Medicaid
days", "ambulatory procedure listing services", and
"ambulatory procedure listing payments" do not include any
days, charges, or services for which Medicare or a managed care
organization reimbursed on a capitated basis was liable for
payment, except where explicitly stated otherwise in this
Section.
    (m) For purposes of this Section, in determining the
percentile ranking of an Illinois hospital's case mix index or
capital costs, hospitals described in subsection (b) of Section
5A-3 shall be excluded from the ranking.
    (n) Definitions. Unless the context requires otherwise or
unless provided otherwise in this Section, the terms used in
this Section for qualifying criteria and payment calculations
shall have the same meanings as those terms have been given in
the Illinois Department's administrative rules as in effect on
March 1, 2008. Other terms shall be defined by the Illinois
Department by rule.
    As used in this Section, unless the context requires
otherwise:
    "Base inpatient payments" means, for a given hospital, the
sum of base payments for inpatient services made on a per diem
or per admission (DRG) basis, excluding those portions of per
admission payments that are classified as capital payments.
Disproportionate share hospital adjustment payments, Medicaid
Percentage Adjustments, Medicaid High Volume Adjustments, and
outlier payments, as defined by rule by the Department as of
January 1, 2008, are not base payments.
    "Capital costs" means, for a given hospital, the total
capital costs determined using the most recent 2005 Medicare
cost report as contained in the Healthcare Cost Report
Information System file, for the quarter ending on December 31,
2006, divided by the total inpatient days from the same cost
report to calculate a capital cost per day. The resulting
capital cost per day is inflated to the midpoint of State
fiscal year 2009 utilizing the national hospital market price
proxies (DRI) hospital cost index. If a hospital's 2005
Medicare cost report is not contained in the Healthcare Cost
Report Information System, the Department may obtain the data
necessary to compute the hospital's capital costs from any
source available, including, but not limited to, records
maintained by the hospital provider, which may be inspected at
all times during business hours of the day by the Illinois
Department or its duly authorized agents and employees.
    "Case mix index" means, for a given hospital, the sum of
the DRG relative weighting factors in effect on January 1,
2005, for all general acute care admissions for State fiscal
year 2005, excluding Medicare crossover admissions and
transplant admissions reimbursed under 89 Ill. Adm. Code
148.82, divided by the total number of general acute care
admissions for State fiscal year 2005, excluding Medicare
crossover admissions and transplant admissions reimbursed
under 89 Ill. Adm. Code 148.82.
    "Medicaid inpatient day" means, for a given hospital, the
sum of days of inpatient hospital days provided to recipients
of medical assistance under Title XIX of the federal Social
Security Act, excluding days for individuals eligible for
Medicare under Title XVIII of that Act (Medicaid/Medicare
crossover days), as tabulated from the Department's paid claims
data for admissions occurring during State fiscal year 2005
that was adjudicated by the Department through March 23, 2007.
    "Medicaid obstetrical day" means, for a given hospital, the
sum of days of inpatient hospital days grouped by the
Department to DRGs of 370 through 375 provided to recipients of
medical assistance under Title XIX of the federal Social
Security Act, excluding days for individuals eligible for
Medicare under Title XVIII of that Act (Medicaid/Medicare
crossover days), as tabulated from the Department's paid claims
data for admissions occurring during State fiscal year 2005
that was adjudicated by the Department through March 23, 2007.
    "Outpatient ambulatory procedure listing payments" means,
for a given hospital, the sum of payments for ambulatory
procedure listing services, as described in 89 Ill. Adm. Code
148.140(b), provided to recipients of medical assistance under
Title XIX of the federal Social Security Act, excluding
payments for individuals eligible for Medicare under Title
XVIII of the Act (Medicaid/Medicare crossover days), as
tabulated from the Department's paid claims data for services
occurring in State fiscal year 2005 that were adjudicated by
the Department through March 23, 2007.
    (o) The Department may adjust payments made under this
Section 5A-12.2 12.2 to comply with federal law or regulations
regarding hospital-specific payment limitations on
government-owned or government-operated hospitals.
    (p) Notwithstanding any of the other provisions of this
Section, the Department is authorized to adopt rules that
change the hospital access improvement payments specified in
this Section, but only to the extent necessary to conform to
any federally approved amendment to the Title XIX State plan.
Any such rules shall be adopted by the Department as authorized
by Section 5-50 of the Illinois Administrative Procedure Act.
Notwithstanding any other provision of law, any changes
implemented as a result of this subsection (p) shall be given
retroactive effect so that they shall be deemed to have taken
effect as of the effective date of this Section.
    (q) (Blank). For State fiscal years 2012 and 2013, the
Department may make recommendations to the General Assembly
regarding the use of more recent data for purposes of
calculating the assessment authorized under Section 5A-2 and
the payments authorized under this Section 5A-12.2.
    (r) On and after July 1, 2012, the Department shall reduce
any rate of reimbursement for services or other payments or
alter any methodologies authorized by this Code to reduce any
rate of reimbursement for services or other payments in
accordance with Section 5-5e.
(Source: P.A. 95-859, eff. 8-19-08; 96-821, eff. 11-20-09.)
 
    (305 ILCS 5/5A-14)
    Sec. 5A-14. Repeal of assessments and disbursements.
    (a) Section 5A-2 is repealed on January 1, 2015 July 1,
2014.
    (b) Section 5A-12 is repealed on July 1, 2005.
    (c) Section 5A-12.1 is repealed on July 1, 2008.
    (d) Section 5A-12.2 is repealed on January 1, 2015 July 1,
2014.
    (e) Section 5A-12.3 is repealed on July 1, 2011.
(Source: P.A. 95-859, eff. 8-19-08; 96-821, eff. 11-20-09;
96-1530, eff. 2-16-11.)
 
    (305 ILCS 5/5A-15 new)
    Sec. 5A-15. Protection of federal revenue.
    (a) If the federal Centers for Medicare and Medicaid
Services finds that any federal upper payment limit applicable
to the payments under this Article is exceeded then:
        (1) the payments under this Article that exceed the
    applicable federal upper payment limit shall be reduced
    uniformly to the extent necessary to comply with the
    applicable federal upper payment limit; and
        (2) any assessment rate imposed under this Article
    shall be reduced such that the aggregate assessment is
    reduced by the same percentage reduction applied in
    paragraph (1); and
        (3) any transfers from the Hospital Provider Fund under
    Section 5A-8 shall be reduced by the same percentage
    reduction applied in paragraph (1).
    (b) Any payment reductions made under the authority granted
in this Section are exempt from the requirements and actions
under Section 5A-10.
 
    (305 ILCS 5/6-11)  (from Ch. 23, par. 6-11)
    Sec. 6-11. State funded General Assistance.
    (a) Effective July 1, 1992, all State funded General
Assistance and related medical benefits shall be governed by
this Section, provided that, notwithstanding any other
provisions of this Code to the contrary, on and after July 1,
2012, the State shall not fund the programs outlined in this
Section. Other parts of this Code or other laws related to
General Assistance shall remain in effect to the extent they do
not conflict with the provisions of this Section. If any other
part of this Code or other laws of this State conflict with the
provisions of this Section, the provisions of this Section
shall control.
    (b) State funded General Assistance may shall consist of 2
separate programs. One program shall be for adults with no
children and shall be known as State Transitional Assistance.
The other program may shall be for families with children and
for pregnant women and shall be known as State Family and
Children Assistance.
    (c) (1) To be eligible for State Transitional Assistance on
or after July 1, 1992, an individual must be ineligible for
assistance under any other Article of this Code, must be
determined chronically needy, and must be one of the following:
        (A) age 18 or over or
        (B) married and living with a spouse, regardless of
    age.
    (2) The Illinois Department or the local governmental unit
shall determine whether individuals are chronically needy as
follows:
        (A) Individuals who have applied for Supplemental
    Security Income (SSI) and are awaiting a decision on
    eligibility for SSI who are determined disabled by the
    Illinois Department using the SSI standard shall be
    considered chronically needy, except that individuals
    whose disability is based solely on substance addictions
    (drug abuse and alcoholism) and whose disability would
    cease were their addictions to end shall be eligible only
    for medical assistance and shall not be eligible for cash
    assistance under the State Transitional Assistance
    program.
        (B) (Blank). If an individual has been denied SSI due
    to a finding of "not disabled" (either at the
    Administrative Law Judge level or above, or at a lower
    level if that determination was not appealed), the Illinois
    Department shall adopt that finding and the individual
    shall not be eligible for State Transitional Assistance or
    any related medical benefits. Such an individual may not be
    determined disabled by the Illinois Department for a period
    of 12 months, unless the individual shows that there has
    been a substantial change in his or her medical condition
    or that there has been a substantial change in other
    factors, such as age or work experience, that might change
    the determination of disability.
        (C) The unit of local government Illinois Department,
    by rule, may specify other categories of individuals as
    chronically needy; nothing in this Section, however, shall
    be deemed to require the inclusion of any specific category
    other than as specified in paragraph paragraphs (A) and
    (B).
    (3) For individuals in State Transitional Assistance,
medical assistance may shall be provided by the unit of local
government in an amount and nature determined by the unit of
local government. Nothing Department of Healthcare and Family
Services by rule. The amount and nature of medical assistance
provided need not be the same as that provided under paragraph
(4) of subsection (d) of this Section, and nothing in this
paragraph (3) shall be construed to require the coverage of any
particular medical service. In addition, the amount and nature
of medical assistance provided may be different for different
categories of individuals determined chronically needy.
    (4) (Blank). The Illinois Department shall determine, by
rule, those assistance recipients under Article VI who shall be
subject to employment, training, or education programs
including Earnfare, the content of those programs, and the
penalties for failure to cooperate in those programs.
    (5) (Blank). The Illinois Department shall, by rule,
establish further eligibility requirements, including but not
limited to residence, need, and the level of payments.
    (d) (1) To be eligible for State Family and Children
Assistance, a family unit must be ineligible for assistance
under any other Article of this Code and must contain a child
who is:
        (A) under age 18 or
        (B) age 18 and a full-time student in a secondary
    school or the equivalent level of vocational or technical
    training, and who may reasonably be expected to complete
    the program before reaching age 19.
    Those children shall be eligible for State Family and
Children Assistance.
    (2) The natural or adoptive parents of the child living in
the same household may be eligible for State Family and
Children Assistance.
    (3) A pregnant woman whose pregnancy has been verified
shall be eligible for income maintenance assistance under the
State Family and Children Assistance program.
    (4) The amount and nature of medical assistance provided
under the State Family and Children Assistance program shall be
determined by the unit of local government Department of
Healthcare and Family Services by rule. The amount and nature
of medical assistance provided need not be the same as that
provided under paragraph (3) of subsection (c) of this Section,
and nothing in this paragraph (4) shall be construed to require
the coverage of any particular medical service.
    (5) (Blank). The Illinois Department shall, by rule,
establish further eligibility requirements, including but not
limited to residence, need, and the level of payments.
    (e) A local governmental unit that chooses to participate
in a General Assistance program under this Section shall
provide funding in accordance with Section 12-21.13 of this
Act. Local governmental funds used to qualify for State funding
may only be expended for clients eligible for assistance under
this Section 6-11 and related administrative expenses.
    (f) (Blank). In order to qualify for State funding under
this Section, a local governmental unit shall be subject to the
supervision and the rules and regulations of the Illinois
Department.
    (g) (Blank). Notwithstanding any other provision in this
Code, the Illinois Department is authorized to reduce payment
levels used to determine cash grants provided to recipients of
State Transitional Assistance at any time within a Fiscal Year
in order to ensure that cash benefits for State Transitional
Assistance do not exceed the amounts appropriated for those
cash benefits. Changes in payment levels may be accomplished by
emergency rule under Section 5-45 of the Illinois
Administrative Procedure Act, except that the limitation on the
number of emergency rules that may be adopted in a 24-month
period shall not apply and the provisions of Sections 5-115 and
5-125 of the Illinois Administrative Procedure Act shall not
apply. This provision shall also be applicable to any reduction
in payment levels made upon implementation of this amendatory
Act of 1995.
(Source: P.A. 95-331, eff. 8-21-07.)
 
    (305 ILCS 5/11-5.2 new)
    Sec. 11-5.2. Income, Residency, and Identity Verification
System.
    (a) The Department shall ensure that its proposed
integrated eligibility system shall include the computerized
functions of income, residency, and identity eligibility
verification to verify eligibility, eliminate duplication of
medical assistance, and deter fraud. Until the integrated
eligibility system is operational, the Department may enter
into a contract with the vendor selected pursuant to Section
11-5.3 as necessary to obtain the electronic data matching
described in this Section. This contract shall be exempt from
the Illinois Procurement Code pursuant to subsection (h) of
Section 1-10 of that Code.
    (b) Prior to awarding medical assistance at application
under Article V of this Code, the Department shall, to the
extent such databases are available to the Department, conduct
data matches using the name, date of birth, address, and Social
Security Number of each applicant or recipient or responsible
relative of an applicant or recipient against the following:
        (1) Income tax information.
        (2) Employer reports of income and unemployment
    insurance payment information maintained by the Department
    of Employment Security.
        (3) Earned and unearned income, citizenship and death,
    and other relevant information maintained by the Social
    Security Administration.
        (4) Immigration status information maintained by the
    United States Citizenship and Immigration Services.
        (5) Wage reporting and similar information maintained
    by states contiguous to this State.
        (6) Employment information maintained by the
    Department of Employment Security in its New Hire Directory
    database.
        (7) Employment information maintained by the United
    States Department of Health and Human Services in its
    National Directory of New Hires database.
        (8) Veterans' benefits information maintained by the
    United States Department of Health and Human Services, in
    coordination with the Department of Health and Human
    Services and the Department of Veterans' Affairs, in the
    federal Public Assistance Reporting Information System
    (PARIS) database.
        (9) Residency information maintained by the Illinois
    Secretary of State.
        (10) A database which is substantially similar to or a
    successor of a database described in this Section that
    contains information relevant for verifying eligibility
    for medical assistance.
    (d) If a discrepancy results between information provided
by an applicant, recipient, or responsible relative and
information contained in one or more of the databases or
information tools listed under subsection (b) or (c) of this
Section or subsection (c) of Section 11-5.3 and that
discrepancy calls into question the accuracy of information
relevant to a condition of eligibility provided by the
applicant, recipient, or responsible relative, the Department
or its contractor shall review the applicant's or recipient's
case using the following procedures:
        (1) If the information discovered under subsection (c)
    of this Section or subsection (c) of Section 11-5.3 does
    not result in the Department finding the applicant or
    recipient ineligible for assistance under Article V of this
    Code, the Department shall finalize the determination or
    redetermination of eligibility.
        (2) If the information discovered results in the
    Department finding the applicant or recipient ineligible
    for assistance, the Department shall provide notice as set
    forth in Section 11-7 of this Article.
        (3) If the information discovered is insufficient to
    determine that the applicant or recipient is eligible or
    ineligible, the Department shall provide written notice to
    the applicant or recipient which shall describe in
    sufficient detail the circumstances of the discrepancy,
    the information or documentation required, the manner in
    which the applicant or recipient may respond, and the
    consequences of failing to take action. The applicant or
    recipient shall have 10 business days to respond.
        (4) If the applicant or recipient does not respond to
    the notice, the Department shall deny assistance for
    failure to cooperate, in which case the Department shall
    provide notice as set forth in Section 11-7. Eligibility
    for assistance shall not be established until the
    discrepancy has been resolved.
        (5) If an applicant or recipient responds to the
    notice, the Department shall determine the effect of the
    information or documentation provided on the applicant's
    or recipient's case and shall take appropriate action.
    Written notice of the Department's action shall be provided
    as set forth in Section 11-7 of this Article.
        (6) Suspected cases of fraud shall be referred to the
    Department's Inspector General.
    (e) The Department shall adopt any rules necessary to
implement this Section.
 
    (305 ILCS 5/11-5.3 new)
    Sec. 11-5.3. Procurement of vendor to verify eligibility
for assistance under Article V.
    (a) No later than 60 days after the effective date of this
amendatory Act of the 97th General Assembly, the Chief
Procurement Officer for General Services, in consultation with
the Department of Healthcare and Family Services, shall conduct
and complete any procurement necessary to procure a vendor to
verify eligibility for assistance under Article V of this Code.
Such authority shall include procuring a vendor to assist the
Chief Procurement Officer in conducting the procurement. The
Chief Procurement Officer and the Department shall jointly
negotiate final contract terms with a vendor selected by the
Chief Procurement Officer. Within 30 days of selection of an
eligibility verification vendor, the Department of Healthcare
and Family Services shall enter into a contract with the
selected vendor. The Department of Healthcare and Family
Services and the Department of Human Services shall cooperate
with and provide any information requested by the Chief
Procurement Officer to conduct the procurement.
    (b) Notwithstanding any other provision of law, any
procurement or contract necessary to comply with this Section
shall be exempt from: (i) the Illinois Procurement Code
pursuant to Section 1-10(h) of the Illinois Procurement Code,
except that bidders shall comply with the disclosure
requirement in Sections 50-10.5(a) through (d), 50-13, 50-35,
and 50-37 of the Illinois Procurement Code and a vendor awarded
a contract under this Section shall comply with Section 50-37
of the Illinois Procurement Code; (ii) any administrative rules
of this State pertaining to procurement or contract formation;
and (iii) any State or Department policies or procedures
pertaining to procurement, contract formation, contract award,
and Business Enterprise Program approval.
    (c) Upon becoming operational, the contractor shall
conduct data matches using the name, date of birth, address,
and Social Security Number of each applicant and recipient
against public records to verify eligibility. The contractor,
upon preliminary determination that an enrollee is eligible or
ineligible, shall notify the Department. Within 20 business
days of such notification, the Department shall accept the
recommendation or reject it with a stated reason. The
Department shall retain final authority over eligibility
determinations. The contractor shall keep a record of all
preliminary determinations of ineligibility communicated to
the Department. Within 30 days of the end of each calendar
quarter, the Department and contractor shall file a joint
report on a quarterly basis to the Governor, the Speaker of the
House of Representatives, the Minority Leader of the House of
Representatives, the Senate President, and the Senate Minority
Leader. The report shall include, but shall not be limited to,
monthly recommendations of preliminary determinations of
eligibility or ineligibility communicated by the contractor,
the actions taken on those preliminary determinations by the
Department, and the stated reasons for those recommendations
that the Department rejected.
    (d) An eligibility verification vendor contract shall be
awarded for an initial 2-year period with up to a maximum of 2
one-year renewal options. Nothing in this Section shall compel
the award of a contract to a vendor that fails to meet the
needs of the Department. A contract with a vendor to assist in
the procurement shall be awarded for a period of time not to
exceed 6 months.
 
    (305 ILCS 5/11-13)  (from Ch. 23, par. 11-13)
    Sec. 11-13. Conditions For Receipt of Vendor Payments -
Limitation Period For Vendor Action - Penalty For Violation. A
vendor payment, as defined in Section 2-5 of Article II, shall
constitute payment in full for the goods or services covered
thereby. Acceptance of the payment by or in behalf of the
vendor shall bar him from obtaining, or attempting to obtain,
additional payment therefor from the recipient or any other
person. A vendor payment shall not, however, bar recovery of
the value of goods and services the obligation for which, under
the rules and regulations of the Illinois Department, is to be
met from the income and resources available to the recipient,
and in respect to which the vendor payment of the Illinois
Department or the local governmental unit represents
supplementation of such available income and resources.
    Vendors seeking to enforce obligations of a governmental
unit or the Illinois Department for goods or services (1)
furnished to or in behalf of recipients and (2) subject to a
vendor payment as defined in Section 2-5, shall commence their
actions in the appropriate Circuit Court or the Court of
Claims, as the case may require, within one year next after the
cause of action accrued.
    A cause of action accrues within the meaning of this
Section upon the following date:
    (1) If the vendor can prove that he submitted a bill for
the service rendered to the Illinois Department or a
governmental unit within 180 days after 12 months of the date
the service was rendered, then (a) upon the date the Illinois
Department or a governmental unit mails to the vendor
information that it is paying a bill in part or is refusing to
pay a bill in whole or in part, or (b) upon the date one year
following the date the vendor submitted such bill if the
Illinois Department or a governmental unit fails to mail to the
vendor such payment information within one year following the
date the vendor submitted the bill; or
    (2) If the vendor cannot prove that he submitted a bill for
the service rendered within 180 days after 12 months of the
date the service was rendered, then upon the date 12 months
following the date the vendor rendered the service to the
recipient.
    In the case of long term care facilities, where the
Illinois Department initiates the monthly billing process for
the vendor, the cause of action shall accrue 12 months after
the last day of the month the service was rendered.
    This paragraph governs only vendor payments as defined in
this Code and as limited by regulations of the Illinois
Department; it does not apply to goods or services purchased or
contracted for by a recipient under circumstances in which the
payment is to be made directly by the recipient.
    Any vendor who accepts a vendor payment and who knowingly
obtains or attempts to obtain additional payment for the goods
or services covered by the vendor payment from the recipient or
any other person shall be guilty of a Class B misdemeanor.
(Source: P.A. 86-430.)
 
    (305 ILCS 5/11-26)  (from Ch. 23, par. 11-26)
    Sec. 11-26. Recipient's abuse of medical care;
restrictions on access to medical care.
    (a) When the Department determines, on the basis of
statistical norms and medical judgment, that a medical care
recipient has received medical services in excess of need and
with such frequency or in such a manner as to constitute an
abuse of the recipient's medical care privileges, the
recipient's access to medical care may be restricted.
    (b) When the Department has determined that a recipient is
abusing his or her medical care privileges as described in this
Section, it may require that the recipient designate a primary
provider type of the recipient's own choosing to assume
responsibility for the recipient's care. For the purposes of
this subsection, "primary provider type" means a provider type
as determined by the Department primary care provider, primary
care pharmacy, primary dentist, primary podiatrist, or primary
durable medical equipment provider. Instead of requiring a
recipient to make a designation as provided in this subsection,
the Department, pursuant to rules adopted by the Department and
without regard to any choice of an entity that the recipient
might otherwise make, may initially designate a primary
provider type provided that the primary provider type is
willing to provide that care.
    (c) When the Department has requested that a recipient
designate a primary provider type and the recipient fails or
refuses to do so, the Department may, after a reasonable period
of time, assign the recipient to a primary provider type of its
own choice and determination, provided such primary provider
type is willing to provide such care.
    (d) When a recipient has been restricted to a designated
primary provider type, the recipient may change the primary
provider type:
        (1) when the designated source becomes unavailable, as
    the Department shall determine by rule; or
        (2) when the designated primary provider type notifies
    the Department that it wishes to withdraw from any
    obligation as primary provider type; or
        (3) in other situations, as the Department shall
    provide by rule.
    The Department shall, by rule, establish procedures for
providing medical or pharmaceutical services when the
designated source becomes unavailable or wishes to withdraw
from any obligation as primary provider type, shall, by rule,
take into consideration the need for emergency or temporary
medical assistance and shall ensure that the recipient has
continuous and unrestricted access to medical care from the
date on which such unavailability or withdrawal becomes
effective until such time as the recipient designates a primary
provider type or a primary provider type willing to provide
such care is designated by the Department consistent with
subsections (b) and (c) and such restriction becomes effective.
    (e) Prior to initiating any action to restrict a
recipient's access to medical or pharmaceutical care, the
Department shall notify the recipient of its intended action.
Such notification shall be in writing and shall set forth the
reasons for and nature of the proposed action. In addition, the
notification shall:
        (1) inform the recipient that (i) the recipient has a
    right to designate a primary provider type of the
    recipient's own choosing willing to accept such
    designation and that the recipient's failure to do so
    within a reasonable time may result in such designation
    being made by the Department or (ii) the Department has
    designated a primary provider type to assume
    responsibility for the recipient's care; and
        (2) inform the recipient that the recipient has a right
    to appeal the Department's determination to restrict the
    recipient's access to medical care and provide the
    recipient with an explanation of how such appeal is to be
    made. The notification shall also inform the recipient of
    the circumstances under which unrestricted medical
    eligibility shall continue until a decision is made on
    appeal and that if the recipient chooses to appeal, the
    recipient will be able to review the medical payment data
    that was utilized by the Department to decide that the
    recipient's access to medical care should be restricted.
    (f) The Department shall, by rule or regulation, establish
procedures for appealing a determination to restrict a
recipient's access to medical care, which procedures shall, at
a minimum, provide for a reasonable opportunity to be heard
and, where the appeal is denied, for a written statement of the
reason or reasons for such denial.
    (g) Except as otherwise provided in this subsection, when a
recipient has had his or her medical card restricted for 4 full
quarters (without regard to any period of ineligibility for
medical assistance under this Code, or any period for which the
recipient voluntarily terminates his or her receipt of medical
assistance, that may occur before the expiration of those 4
full quarters), the Department shall reevaluate the
recipient's medical usage to determine whether it is still in
excess of need and with such frequency or in such a manner as
to constitute an abuse of the receipt of medical assistance. If
it is still in excess of need, the restriction shall be
continued for another 4 full quarters. If it is no longer in
excess of need, the restriction shall be discontinued. If a
recipient's access to medical care has been restricted under
this Section and the Department then determines, either at
reevaluation or after the restriction has been discontinued, to
restrict the recipient's access to medical care a second or
subsequent time, the second or subsequent restriction may be
imposed for a period of more than 4 full quarters. If the
Department restricts a recipient's access to medical care for a
period of more than 4 full quarters, as determined by rule, the
Department shall reevaluate the recipient's medical usage
after the end of the restriction period rather than after the
end of 4 full quarters. The Department shall notify the
recipient, in writing, of any decision to continue the
restriction and the reason or reasons therefor. A "quarter",
for purposes of this Section, shall be defined as one of the
following 3-month periods of time: January-March, April-June,
July-September or October-December.
    (h) In addition to any other recipient whose acquisition of
medical care is determined to be in excess of need, the
Department may restrict the medical care privileges of the
following persons:
        (1) recipients found to have loaned or altered their
    cards or misused or falsely represented medical coverage;
        (2) recipients found in possession of blank or forged
    prescription pads;
        (3) recipients who knowingly assist providers in
    rendering excessive services or defrauding the medical
    assistance program.
    The procedural safeguards in this Section shall apply to
the above individuals.
    (i) Restrictions under this Section shall be in addition to
and shall not in any way be limited by or limit any actions
taken under Article VIII-A of this Code.
(Source: P.A. 96-1501, eff. 1-25-11.)
 
    (305 ILCS 5/12-4.25)  (from Ch. 23, par. 12-4.25)
    Sec. 12-4.25. Medical assistance program; vendor
participation.
    (A) The Illinois Department may deny, suspend, or terminate
the eligibility of any person, firm, corporation, association,
agency, institution or other legal entity to participate as a
vendor of goods or services to recipients under the medical
assistance program under Article V, or may exclude any such
person or entity from participation as such a vendor, and may
deny, suspend, or recover payments, if after reasonable notice
and opportunity for a hearing the Illinois Department finds:
        (a) Such vendor is not complying with the Department's
    policy or rules and regulations, or with the terms and
    conditions prescribed by the Illinois Department in its
    vendor agreement, which document shall be developed by the
    Department as a result of negotiations with each vendor
    category, including physicians, hospitals, long term care
    facilities, pharmacists, optometrists, podiatrists and
    dentists setting forth the terms and conditions applicable
    to the participation of each vendor group in the program;
    or
        (b) Such vendor has failed to keep or make available
    for inspection, audit or copying, after receiving a written
    request from the Illinois Department, such records
    regarding payments claimed for providing services. This
    section does not require vendors to make available patient
    records of patients for whom services are not reimbursed
    under this Code; or
        (c) Such vendor has failed to furnish any information
    requested by the Department regarding payments for
    providing goods or services; or
        (d) Such vendor has knowingly made, or caused to be
    made, any false statement or representation of a material
    fact in connection with the administration of the medical
    assistance program; or
        (e) Such vendor has furnished goods or services to a
    recipient which are (1) in excess of need his or her needs,
    (2) harmful to the recipient, or (3) of grossly inferior
    quality, all of such determinations to be based upon
    competent medical judgment and evaluations; or
        (f) The vendor; a person with management
    responsibility for a vendor; an officer or person owning,
    either directly or indirectly, 5% or more of the shares of
    stock or other evidences of ownership in a corporate
    vendor; an owner of a sole proprietorship which is a
    vendor; or a partner in a partnership which is a vendor,
    either:
            (1) was previously terminated, suspended, or
        excluded from participation in the Illinois medical
        assistance program, or was terminated, suspended, or
        excluded from participation in another state or
        federal medical assistance or health care program a
        medical assistance program in another state that is of
        the same kind as the program of medical assistance
        provided under Article V of this Code; or
            (2) was a person with management responsibility
        for a vendor previously terminated, suspended, or
        excluded from participation in the Illinois medical
        assistance program, or terminated, suspended, or
        excluded from participation in another state or
        federal a medical assistance or health care program in
        another state that is of the same kind as the program
        of medical assistance provided under Article V of this
        Code, during the time of conduct which was the basis
        for that vendor's termination, suspension, or
        exclusion; or
            (3) was an officer, or person owning, either
        directly or indirectly, 5% or more of the shares of
        stock or other evidences of ownership in a corporate or
        limited liability company vendor previously
        terminated, suspended, or excluded from participation
        in the Illinois medical assistance program, or
        terminated, suspended, or excluded from participation
        in a state or federal medical assistance or health care
        program in another state that is of the same kind as
        the program of medical assistance provided under
        Article V of this Code, during the time of conduct
        which was the basis for that vendor's termination,
        suspension, or exclusion; or
            (4) was an owner of a sole proprietorship or
        partner of a partnership previously terminated,
        suspended, or excluded from participation in the
        Illinois medical assistance program, or terminated,
        suspended, or excluded from participation in a state or
        federal medical assistance or health care program in
        another state that is of the same kind as the program
        of medical assistance provided under Article V of this
        Code, during the time of conduct which was the basis
        for that vendor's termination, suspension, or
        exclusion; or
        (f-1) Such vendor has a delinquent debt owed to the
    Illinois Department; or
        (g) The vendor; a person with management
    responsibility for a vendor; an officer or person owning,
    either directly or indirectly, 5% or more of the shares of
    stock or other evidences of ownership in a corporate or
    limited liability company vendor; an owner of a sole
    proprietorship which is a vendor; or a partner in a
    partnership which is a vendor, either:
            (1) has engaged in practices prohibited by
        applicable federal or State law or regulation relating
        to the medical assistance program; or
            (2) was a person with management responsibility
        for a vendor at the time that such vendor engaged in
        practices prohibited by applicable federal or State
        law or regulation relating to the medical assistance
        program; or
            (3) was an officer, or person owning, either
        directly or indirectly, 5% or more of the shares of
        stock or other evidences of ownership in a vendor at
        the time such vendor engaged in practices prohibited by
        applicable federal or State law or regulation relating
        to the medical assistance program; or
            (4) was an owner of a sole proprietorship or
        partner of a partnership which was a vendor at the time
        such vendor engaged in practices prohibited by
        applicable federal or State law or regulation relating
        to the medical assistance program; or
        (h) The direct or indirect ownership of the vendor
    (including the ownership of a vendor that is a sole
    proprietorship, a partner's interest in a vendor that is a
    partnership, or ownership of 5% or more of the shares of
    stock or other evidences of ownership in a corporate
    vendor) has been transferred by an individual who is
    terminated, suspended, or excluded or barred from
    participating as a vendor to the individual's spouse,
    child, brother, sister, parent, grandparent, grandchild,
    uncle, aunt, niece, nephew, cousin, or relative by
    marriage.
    (A-5) The Illinois Department may deny, suspend, or
terminate the eligibility of any person, firm, corporation,
association, agency, institution, or other legal entity to
participate as a vendor of goods or services to recipients
under the medical assistance program under Article V, or may
exclude any such person or entity from participation as such a
vendor, if, after reasonable notice and opportunity for a
hearing, the Illinois Department finds that the vendor; a
person with management responsibility for a vendor; an officer
or person owning, either directly or indirectly, 5% or more of
the shares of stock or other evidences of ownership in a
corporate vendor; an owner of a sole proprietorship that is a
vendor; or a partner in a partnership that is a vendor has been
convicted of an a felony offense based on fraud or willful
misrepresentation related to any of the following:
        (1) The medical assistance program under Article V of
    this Code.
        (2) A medical assistance or health care program in
    another state that is of the same kind as the program of
    medical assistance provided under Article V of this Code.
        (3) The Medicare program under Title XVIII of the
    Social Security Act.
        (4) The provision of health care services.
        (5) A violation of this Code, as provided in Article
    VIIIA, or another state or federal medical assistance
    program or health care program.
    (A-10) The Illinois Department may deny, suspend, or
terminate the eligibility of any person, firm, corporation,
association, agency, institution, or other legal entity to
participate as a vendor of goods or services to recipients
under the medical assistance program under Article V, or may
exclude any such person or entity from participation as such a
vendor, if, after reasonable notice and opportunity for a
hearing, the Illinois Department finds that (i) the vendor,
(ii) a person with management responsibility for a vendor,
(iii) an officer or person owning, either directly or
indirectly, 5% or more of the shares of stock or other
evidences of ownership in a corporate vendor, (iv) an owner of
a sole proprietorship that is a vendor, or (v) a partner in a
partnership that is a vendor has been convicted of an a felony
offense related to any of the following:
        (1) Murder.
        (2) A Class X felony under the Criminal Code of 1961.
        (3) Sexual misconduct that may subject recipients to an
    undue risk of harm.
        (4) A criminal offense that may subject recipients to
    an undue risk of harm.
        (5) A crime of fraud or dishonesty.
        (6) A crime involving a controlled substance.
        (7) A misdemeanor relating to fraud, theft,
    embezzlement, breach of fiduciary responsibility, or other
    financial misconduct related to a health care program.
    (A-15) The Illinois Department may deny the eligibility of
any person, firm, corporation, association, agency,
institution, or other legal entity to participate as a vendor
of goods or services to recipients under the medical assistance
program under Article V if, after reasonable notice and
opportunity for a hearing, the Illinois Department finds:
        (1) The applicant or any person with management
    responsibility for the applicant; an officer or member of
    the board of directors of an applicant; an entity owning
    (directly or indirectly) 5% or more of the shares of stock
    or other evidences of ownership in a corporate vendor
    applicant; an owner of a sole proprietorship applicant; a
    partner in a partnership applicant; or a technical or other
    advisor to an applicant has a debt owed to the Illinois
    Department, and no payment arrangements acceptable to the
    Illinois Department have been made by the applicant.
        (2) The applicant or any person with management
    responsibility for the applicant; an officer or member of
    the board of directors of an applicant; an entity owning
    (directly or indirectly) 5% or more of the shares of stock
    or other evidences of ownership in a corporate vendor
    applicant; an owner of a sole proprietorship applicant; a
    partner in a partnership vendor applicant; or a technical
    or other advisor to an applicant was (i) a person with
    management responsibility, (ii) an officer or member of the
    board of directors of an applicant, (iii) an entity owning
    (directly or indirectly) 5% or more of the shares of stock
    or other evidences of ownership in a corporate vendor, (iv)
    an owner of a sole proprietorship, (v) a partner in a
    partnership vendor, (vi) a technical or other advisor to a
    vendor, during a period of time where the conduct of that
    vendor resulted in a debt owed to the Illinois Department,
    and no payment arrangements acceptable to the Illinois
    Department have been made by that vendor.
        (3) There is a credible allegation of the use,
    transfer, or lease of assets of any kind to an applicant
    from a current or prior vendor who has a debt owed to the
    Illinois Department, no payment arrangements acceptable to
    the Illinois Department have been made by that vendor or
    the vendor's alternate payee, and the applicant knows or
    should have known of such debt.
        (4) There is a credible allegation of a transfer of
    management responsibilities, or direct or indirect
    ownership, to an applicant from a current or prior vendor
    who has a debt owed to the Illinois Department, and no
    payment arrangements acceptable to the Illinois Department
    have been made by that vendor or the vendor's alternate
    payee, and the applicant knows or should have known of such
    debt.
        (5) There is a credible allegation of the use,
    transfer, or lease of assets of any kind to an applicant
    who is a spouse, child, brother, sister, parent,
    grandparent, grandchild, uncle, aunt, niece, relative by
    marriage, nephew, cousin, or relative of a current or prior
    vendor who has a debt owed to the Illinois Department and
    no payment arrangements acceptable to the Illinois
    Department have been made.
        (6) There is a credible allegation that the applicant's
    previous affiliations with a provider of medical services
    that has an uncollected debt, a provider that has been or
    is subject to a payment suspension under a federal health
    care program, or a provider that has been previously
    excluded from participation in the medical assistance
    program, poses a risk of fraud, waste, or abuse to the
    Illinois Department.
    As used in this subsection, "credible allegation" is
defined to include an allegation from any source, including,
but not limited to, fraud hotline complaints, claims data
mining, patterns identified through provider audits, civil
actions filed under the False Claims Act, and law enforcement
investigations. An allegation is considered to be credible when
it has indicia of reliability.
    (B) The Illinois Department shall deny, suspend or
terminate the eligibility of any person, firm, corporation,
association, agency, institution or other legal entity to
participate as a vendor of goods or services to recipients
under the medical assistance program under Article V, or may
exclude any such person or entity from participation as such a
vendor:
        (1) immediately, if such vendor is not properly
    licensed, certified, or authorized;
        (2) within 30 days of the date when such vendor's
    professional license, certification or other authorization
    has been refused renewal, restricted, or has been revoked,
    suspended, or otherwise terminated; or
        (3) if such vendor has been convicted of a violation of
    this Code, as provided in Article VIIIA.
    (C) Upon termination, suspension, or exclusion of a vendor
of goods or services from participation in the medical
assistance program authorized by this Article, a person with
management responsibility for such vendor during the time of
any conduct which served as the basis for that vendor's
termination, suspension, or exclusion is barred from
participation in the medical assistance program.
    Upon termination, suspension, or exclusion of a corporate
vendor, the officers and persons owning, directly or
indirectly, 5% or more of the shares of stock or other
evidences of ownership in the vendor during the time of any
conduct which served as the basis for that vendor's
termination, suspension, or exclusion are barred from
participation in the medical assistance program. A person who
owns, directly or indirectly, 5% or more of the shares of stock
or other evidences of ownership in a terminated, suspended, or
excluded corporate vendor may not transfer his or her ownership
interest in that vendor to his or her spouse, child, brother,
sister, parent, grandparent, grandchild, uncle, aunt, niece,
nephew, cousin, or relative by marriage.
    Upon termination, suspension, or exclusion of a sole
proprietorship or partnership, the owner or partners during the
time of any conduct which served as the basis for that vendor's
termination, suspension, or exclusion are barred from
participation in the medical assistance program. The owner of a
terminated, suspended, or excluded vendor that is a sole
proprietorship, and a partner in a terminated, suspended, or
excluded vendor that is a partnership, may not transfer his or
her ownership or partnership interest in that vendor to his or
her spouse, child, brother, sister, parent, grandparent,
grandchild, uncle, aunt, niece, nephew, cousin, or relative by
marriage.
    A person who owns, directly or indirectly, 5% or more of
the shares of stock or other evidences of ownership in a
corporate or limited liability company vendor who owes a debt
to the Department, if that vendor has not made payment
arrangements acceptable to the Department, shall not transfer
his or her ownership interest in that vendor, or vendor assets
of any kind, to his or her spouse, child, brother, sister,
parent, grandparent, grandchild, uncle, aunt, niece, nephew,
cousin, or relative by marriage.
    Rules adopted by the Illinois Department to implement these
provisions shall specifically include a definition of the term
"management responsibility" as used in this Section. Such
definition shall include, but not be limited to, typical job
titles, and duties and descriptions which will be considered as
within the definition of individuals with management
responsibility for a provider.
    A vendor or a prior vendor who has been terminated,
excluded, or suspended from the medical assistance program, or
from another state or federal medical assistance or health care
program, and any individual currently or previously barred from
the medical assistance program, or from another state or
federal medical assistance or health care program, as a result
of being an officer or a person owning, directly or indirectly,
5% or more of the shares of stock or other evidences of
ownership in a corporate or limited liability company vendor
during the time of any conduct which served as the basis for
that vendor's termination, suspension, or exclusion, may be
required to post a surety bond as part of a condition of
enrollment or participation in the medical assistance program.
The Illinois Department shall establish, by rule, the criteria
and requirements for determining when a surety bond must be
posted and the value of the bond.
    A vendor or a prior vendor who has a debt owed to the
Illinois Department and any individual currently or previously
barred from the medical assistance program, or from another
state or federal medical assistance or health care program, as
a result of being an officer or a person owning, directly or
indirectly, 5% or more of the shares of stock or other
evidences of ownership in that corporate or limited liability
company vendor during the time of any conduct which served as
the basis for the debt, may be required to post a surety bond
as part of a condition of enrollment or participation in the
medical assistance program. The Illinois Department shall
establish, by rule, the criteria and requirements for
determining when a surety bond must be posted and the value of
the bond.
    (D) If a vendor has been suspended from the medical
assistance program under Article V of the Code, the Director
may require that such vendor correct any deficiencies which
served as the basis for the suspension. The Director shall
specify in the suspension order a specific period of time,
which shall not exceed one year from the date of the order,
during which a suspended vendor shall not be eligible to
participate. At the conclusion of the period of suspension the
Director shall reinstate such vendor, unless he finds that such
vendor has not corrected deficiencies upon which the suspension
was based.
    If a vendor has been terminated, suspended, or excluded
from the medical assistance program under Article V, such
vendor shall be barred from participation for at least one
year, except that if a vendor has been terminated, suspended,
or excluded based on a conviction of a violation of Article
VIIIA or a conviction of a felony based on fraud or a willful
misrepresentation related to (i) the medical assistance
program under Article V, (ii) a federal or another state's
medical assistance or health care program in another state that
is of the kind provided under Article V, (iii) the Medicare
program under Title XVIII of the Social Security Act, or (iii)
(iv) the provision of health care services, then the vendor
shall be barred from participation for 5 years or for the
length of the vendor's sentence for that conviction, whichever
is longer. At the end of one year a vendor who has been
terminated, suspended, or excluded may apply for reinstatement
to the program. Upon proper application to be reinstated such
vendor may be deemed eligible by the Director providing that
such vendor meets the requirements for eligibility under this
Code. If such vendor is deemed not eligible for reinstatement,
he shall be barred from again applying for reinstatement for
one year from the date his application for reinstatement is
denied.
    A vendor whose termination, suspension, or exclusion from
participation in the Illinois medical assistance program under
Article V was based solely on an action by a governmental
entity other than the Illinois Department may, upon
reinstatement by that governmental entity or upon reversal of
the termination, suspension, or exclusion, apply for
rescission of the termination, suspension, or exclusion from
participation in the Illinois medical assistance program. Upon
proper application for rescission, the vendor may be deemed
eligible by the Director if the vendor meets the requirements
for eligibility under this Code.
    If a vendor has been terminated, suspended, or excluded and
reinstated to the medical assistance program under Article V
and the vendor is terminated, suspended, or excluded a second
or subsequent time from the medical assistance program, the
vendor shall be barred from participation for at least 2 years,
except that if a vendor has been terminated, suspended, or
excluded a second time based on a conviction of a violation of
Article VIIIA or a conviction of a felony based on fraud or a
willful misrepresentation related to (i) the medical
assistance program under Article V, (ii) a federal or another
state's medical assistance or health care program in another
state that is of the kind provided under Article V, (iii) the
Medicare program under Title XVIII of the Social Security Act,
or (iii) (iv) the provision of health care services, then the
vendor shall be barred from participation for life. At the end
of 2 years, a vendor who has been terminated, suspended, or
excluded may apply for reinstatement to the program. Upon
application to be reinstated, the vendor may be deemed eligible
if the vendor meets the requirements for eligibility under this
Code. If the vendor is deemed not eligible for reinstatement,
the vendor shall be barred from again applying for
reinstatement for 2 years from the date the vendor's
application for reinstatement is denied.
    (E) The Illinois Department may recover money improperly or
erroneously paid, or overpayments, either by setoff, crediting
against future billings or by requiring direct repayment to the
Illinois Department. The Illinois Department may suspend or
deny payment, in whole or in part, if such payment would be
improper or erroneous or would otherwise result in overpayment.
        (1) Payments may be suspended, denied, or recovered
    from a vendor or alternate payee: (i) for services rendered
    in violation of the Illinois Department's provider
    notices, statutes, rules, and regulations; (ii) for
    services rendered in violation of the terms and conditions
    prescribed by the Illinois Department in its vendor
    agreement; (iii) for any vendor who fails to grant the
    Office of Inspector General timely access to full and
    complete records, including, but not limited to, records
    relating to recipients under the medical assistance
    program for the most recent 6 years, in accordance with
    Section 140.28 of Title 89 of the Illinois Administrative
    Code, and other information for the purpose of audits,
    investigations, or other program integrity functions,
    after reasonable written request by the Inspector General;
    this subsection (E) does not require vendors to make
    available the medical records of patients for whom services
    are not reimbursed under this Code or to provide access to
    medical records more than 6 years old; (iv) when the vendor
    has knowingly made, or caused to be made, any false
    statement or representation of a material fact in
    connection with the administration of the medical
    assistance program; or (v) when the vendor previously
    rendered services while terminated, suspended, or excluded
    from participation in the medical assistance program or
    while terminated or excluded from participation in another
    state or federal medical assistance or health care program.
        (2) Notwithstanding any other provision of law, if a
    vendor has the same taxpayer identification number
    (assigned under Section 6109 of the Internal Revenue Code
    of 1986) as is assigned to a vendor with past-due financial
    obligations to the Illinois Department, the Illinois
    Department may make any necessary adjustments to payments
    to that vendor in order to satisfy any past-due
    obligations, regardless of whether the vendor is assigned a
    different billing number under the medical assistance
    program.
    If the Illinois Department establishes through an
administrative hearing that the overpayments resulted from the
vendor or alternate payee knowingly willfully making, using, or
causing to be made or used, a false record or statement to
obtain payment or other benefit from or misrepresentation of a
material fact in connection with billings and payments under
the medical assistance program under Article V, the Department
may recover interest on the amount of the payment or other
benefit overpayments at the rate of 5% per annum. In addition
to any other penalties that may be prescribed by law, such a
vendor or alternate payee shall be subject to civil penalties
consisting of an amount not to exceed 3 times the amount of
payment or other benefit resulting from each such false record
or statement, and the sum of $2,000 for each such false record
or statement for payment or other benefit. For purposes of this
paragraph, "knowingly" "willfully" means that a vendor or
alternate payee with respect to information: (i) has person
makes a statement or representation with actual knowledge of
the information, (ii) acts in deliberate ignorance of the truth
or falsity of the information, or (iii) acts in reckless
disregard of the truth or falsity of the information. No proof
of specific intent to defraud is required. that it was false,
or makes a statement or representation with knowledge of facts
or information that would cause one to be aware that the
statement or representation was false when made.
    (F) The Illinois Department may withhold payments to any
vendor or alternate payee prior to or during the pendency of
any audit or proceeding under this Section, and through the
pendency of any administrative appeal or administrative review
by any court proceeding. The Illinois Department shall state by
rule with as much specificity as practicable the conditions
under which payments will not be withheld during the pendency
of any proceeding under this Section. Payments may be denied
for bills submitted with service dates occurring during the
pendency of a proceeding, after a final decision has been
rendered, or after the conclusion of any administrative appeal,
where the final administrative decision is to terminate,
exclude, or suspend eligibility to participate in the medical
assistance program. The Illinois Department shall state by rule
with as much specificity as practicable the conditions under
which payments will not be denied for such bills. The Illinois
Department shall state by rule a process and criteria by which
a vendor or alternate payee may request full or partial release
of payments withheld under this subsection. The Department must
complete a proceeding under this Section in a timely manner.
    Notwithstanding recovery allowed under subsection (E) or
this subsection (F), the Illinois Department may withhold
payments to any vendor or alternate payee who is not properly
licensed, certified, or in compliance with State or federal
agency regulations. Payments may be denied for bills submitted
with service dates occurring during the period of time that a
vendor is not properly licensed, certified, or in compliance
with State or federal regulations. Facilities licensed under
the Nursing Home Care Act shall have payments denied or
withheld pursuant to subsection (I) of this Section.
    (F-5) The Illinois Department may temporarily withhold
payments to a vendor or alternate payee if any of the following
individuals have been indicted or otherwise charged under a law
of the United States or this or any other state with an a
felony offense that is based on alleged fraud or willful
misrepresentation on the part of the individual related to (i)
the medical assistance program under Article V of this Code,
(ii) a federal or another state's medical assistance or health
care program provided in another state which is of the kind
provided under Article V of this Code, (iii) the Medicare
program under Title XVIII of the Social Security Act, or (iii)
(iv) the provision of health care services:
        (1) If the vendor or alternate payee is a corporation:
    an officer of the corporation or an individual who owns,
    either directly or indirectly, 5% or more of the shares of
    stock or other evidence of ownership of the corporation.
        (2) If the vendor is a sole proprietorship: the owner
    of the sole proprietorship.
        (3) If the vendor or alternate payee is a partnership:
    a partner in the partnership.
        (4) If the vendor or alternate payee is any other
    business entity authorized by law to transact business in
    this State: an officer of the entity or an individual who
    owns, either directly or indirectly, 5% or more of the
    evidences of ownership of the entity.
    If the Illinois Department withholds payments to a vendor
or alternate payee under this subsection, the Department shall
not release those payments to the vendor or alternate payee
while any criminal proceeding related to the indictment or
charge is pending unless the Department determines that there
is good cause to release the payments before completion of the
proceeding. If the indictment or charge results in the
individual's conviction, the Illinois Department shall retain
all withheld payments, which shall be considered forfeited to
the Department. If the indictment or charge does not result in
the individual's conviction, the Illinois Department shall
release to the vendor or alternate payee all withheld payments.
    (F-10) If the Illinois Department establishes that the
vendor or alternate payee owes a debt to the Illinois
Department, and the vendor or alternate payee subsequently
fails to pay or make satisfactory payment arrangements with the
Illinois Department for the debt owed, the Illinois Department
may seek all remedies available under the law of this State to
recover the debt, including, but not limited to, wage
garnishment or the filing of claims or liens against the vendor
or alternate payee.
    (F-15) Enforcement of judgment.
        (1) Any fine, recovery amount, other sanction, or costs
    imposed, or part of any fine, recovery amount, other
    sanction, or cost imposed, remaining unpaid after the
    exhaustion of or the failure to exhaust judicial review
    procedures under the Illinois Administrative Review Law is
    a debt due and owing the State and may be collected using
    all remedies available under the law.
        (2) After expiration of the period in which judicial
    review under the Illinois Administrative Review Law may be
    sought for a final administrative decision, unless stayed
    by a court of competent jurisdiction, the findings,
    decision, and order of the Director may be enforced in the
    same manner as a judgment entered by a court of competent
    jurisdiction.
        (3) In any case in which any person or entity has
    failed to comply with a judgment ordering or imposing any
    fine or other sanction, any expenses incurred by the
    Illinois Department to enforce the judgment, including,
    but not limited to, attorney's fees, court costs, and costs
    related to property demolition or foreclosure, after they
    are fixed by a court of competent jurisdiction or the
    Director, shall be a debt due and owing the State and may
    be collected in accordance with applicable law. Prior to
    any expenses being fixed by a final administrative decision
    pursuant to this subsection (F-15), the Illinois
    Department shall provide notice to the individual or entity
    that states that the individual or entity shall appear at a
    hearing before the administrative hearing officer to
    determine whether the individual or entity has failed to
    comply with the judgment. The notice shall set the date for
    such a hearing, which shall not be less than 7 days from
    the date that notice is served. If notice is served by
    mail, the 7-day period shall begin to run on the date that
    the notice was deposited in the mail.
        (4) Upon being recorded in the manner required by
    Article XII of the Code of Civil Procedure or by the
    Uniform Commercial Code, a lien shall be imposed on the
    real estate or personal estate, or both, of the individual
    or entity in the amount of any debt due and owing the State
    under this Section. The lien may be enforced in the same
    manner as a judgment of a court of competent jurisdiction.
    A lien shall attach to all property and assets of such
    person, firm, corporation, association, agency,
    institution, or other legal entity until the judgment is
    satisfied.
        (5) The Director may set aside any judgment entered by
    default and set a new hearing date upon a petition filed at
    any time (i) if the petitioner's failure to appear at the
    hearing was for good cause, or (ii) if the petitioner
    established that the Department did not provide proper
    service of process. If any judgment is set aside pursuant
    to this paragraph (5), the hearing officer shall have
    authority to enter an order extinguishing any lien which
    has been recorded for any debt due and owing the Illinois
    Department as a result of the vacated default judgment.
    (G) The provisions of the Administrative Review Law, as now
or hereafter amended, and the rules adopted pursuant thereto,
shall apply to and govern all proceedings for the judicial
review of final administrative decisions of the Illinois
Department under this Section. The term "administrative
decision" is defined as in Section 3-101 of the Code of Civil
Procedure.
    (G-5) Vendors who pose a risk of fraud, waste, abuse, or
harm Non-emergency transportation.
        (1) Notwithstanding any other provision in this
    Section, for non-emergency transportation vendors, the
    Department may terminate, suspend, or exclude vendors who
    pose a risk of fraud, waste, abuse, or harm the vendor from
    participation in the medical assistance program prior to an
    evidentiary hearing but after reasonable notice and
    opportunity to respond as established by the Department by
    rule.
        (2) Vendors who pose a risk of fraud, waste, abuse, or
    harm of non-emergency medical transportation services, as
    defined by the Department by rule, shall submit to a
    fingerprint-based criminal background check on current and
    future information available in the State system and
    current information available through the Federal Bureau
    of Investigation's system by submitting all necessary fees
    and information in the form and manner prescribed by the
    Department of State Police. The following individuals
    shall be subject to the check:
            (A) In the case of a vendor that is a corporation,
        every shareholder who owns, directly or indirectly, 5%
        or more of the outstanding shares of the corporation.
            (B) In the case of a vendor that is a partnership,
        every partner.
            (C) In the case of a vendor that is a sole
        proprietorship, the sole proprietor.
            (D) Each officer or manager of the vendor.
        Each such vendor shall be responsible for payment of
    the cost of the criminal background check.
        (3) Vendors who pose a risk of fraud, waste, abuse, or
    harm of non-emergency medical transportation services may
    be required to post a surety bond. The Department shall
    establish, by rule, the criteria and requirements for
    determining when a surety bond must be posted and the value
    of the bond.
        (4) The Department, or its agents, may refuse to accept
    requests for authorization from specific vendors who pose a
    risk of fraud, waste, abuse, or harm non-emergency
    transportation authorizations, including prior-approval
    and post-approval requests, for a specific non-emergency
    transportation vendor if:
            (A) the Department has initiated a notice of
        termination, suspension, or exclusion of the vendor
        from participation in the medical assistance program;
        or
            (B) the Department has issued notification of its
        withholding of payments pursuant to subsection (F-5)
        of this Section; or
            (C) the Department has issued a notification of its
        withholding of payments due to reliable evidence of
        fraud or willful misrepresentation pending
        investigation.
        (5) As used in this subsection, the following terms are
    defined as follows:
            (A) "Fraud" means an intentional deception or
        misrepresentation made by a person with the knowledge
        that the deception could result in some unauthorized
        benefit to himself or herself or some other person. It
        includes any act that constitutes fraud under
        applicable federal or State law.
            (B) "Abuse" means provider practices that are
        inconsistent with sound fiscal, business, or medical
        practices and that result in an unnecessary cost to the
        medical assistance program or in reimbursement for
        services that are not medically necessary or that fail
        to meet professionally recognized standards for health
        care. It also includes recipient practices that result
        in unnecessary cost to the medical assistance program.
        Abuse does not include diagnostic or therapeutic
        measures conducted primarily as a safeguard against
        possible vendor liability.
            (C) "Waste" means the unintentional misuse of
        medical assistance resources, resulting in unnecessary
        cost to the medical assistance program. Waste does not
        include diagnostic or therapeutic measures conducted
        primarily as a safeguard against possible vendor
        liability.
            (D) "Harm" means physical, mental, or monetary
        damage to recipients or to the medical assistance
        program.
    (G-6) The Illinois Department, upon making a determination
based upon information in the possession of the Illinois
Department that continuation of participation in the medical
assistance program by a vendor would constitute an immediate
danger to the public, may immediately suspend such vendor's
participation in the medical assistance program without a
hearing. In instances in which the Illinois Department
immediately suspends the medical assistance program
participation of a vendor under this Section, a hearing upon
the vendor's participation must be convened by the Illinois
Department within 15 days after such suspension and completed
without appreciable delay. Such hearing shall be held to
determine whether to recommend to the Director that the
vendor's medical assistance program participation be denied,
terminated, suspended, placed on provisional status, or
reinstated. In the hearing, any evidence relevant to the vendor
constituting an immediate danger to the public may be
introduced against such vendor; provided, however, that the
vendor, or his or her counsel, shall have the opportunity to
discredit, impeach, and submit evidence rebutting such
evidence.
    (H) Nothing contained in this Code shall in any way limit
or otherwise impair the authority or power of any State agency
responsible for licensing of vendors.
    (I) Based on a finding of noncompliance on the part of a
nursing home with any requirement for certification under Title
XVIII or XIX of the Social Security Act (42 U.S.C. Sec. 1395 et
seq. or 42 U.S.C. Sec. 1396 et seq.), the Illinois Department
may impose one or more of the following remedies after notice
to the facility:
        (1) Termination of the provider agreement.
        (2) Temporary management.
        (3) Denial of payment for new admissions.
        (4) Civil money penalties.
        (5) Closure of the facility in emergency situations or
    transfer of residents, or both.
        (6) State monitoring.
        (7) Denial of all payments when the U.S. Department of
    Health and Human Services Health Care Finance
    Administration has imposed this sanction.
    The Illinois Department shall by rule establish criteria
governing continued payments to a nursing facility subsequent
to termination of the facility's provider agreement if, in the
sole discretion of the Illinois Department, circumstances
affecting the health, safety, and welfare of the facility's
residents require those continued payments. The Illinois
Department may condition those continued payments on the
appointment of temporary management, sale of the facility to
new owners or operators, or other arrangements that the
Illinois Department determines best serve the needs of the
facility's residents.
    Except in the case of a facility that has a right to a
hearing on the finding of noncompliance before an agency of the
federal government, a facility may request a hearing before a
State agency on any finding of noncompliance within 60 days
after the notice of the intent to impose a remedy. Except in
the case of civil money penalties, a request for a hearing
shall not delay imposition of the penalty. The choice of
remedies is not appealable at a hearing. The level of
noncompliance may be challenged only in the case of a civil
money penalty. The Illinois Department shall provide by rule
for the State agency that will conduct the evidentiary
hearings.
    The Illinois Department may collect interest on unpaid
civil money penalties.
    The Illinois Department may adopt all rules necessary to
implement this subsection (I).
    (J) The Illinois Department, by rule, may permit individual
practitioners to designate that Department payments that may be
due the practitioner be made to an alternate payee or alternate
payees.
        (a) Such alternate payee or alternate payees shall be
    required to register as an alternate payee in the Medical
    Assistance Program with the Illinois Department.
        (b) If a practitioner designates an alternate payee,
    the alternate payee and practitioner shall be jointly and
    severally liable to the Department for payments made to the
    alternate payee. Pursuant to subsection (E) of this
    Section, any Department action to suspend or deny payment
    or recover money or overpayments from an alternate payee
    shall be subject to an administrative hearing.
        (c) Registration as an alternate payee or alternate
    payees in the Illinois Medical Assistance Program shall be
    conditional. At any time, the Illinois Department may deny
    or cancel any alternate payee's registration in the
    Illinois Medical Assistance Program without cause. Any
    such denial or cancellation is not subject to an
    administrative hearing.
        (d) The Illinois Department may seek a revocation of
    any alternate payee, and all owners, officers, and
    individuals with management responsibility for such
    alternate payee shall be permanently prohibited from
    participating as an owner, an officer, or an individual
    with management responsibility with an alternate payee in
    the Illinois Medical Assistance Program, if after
    reasonable notice and opportunity for a hearing the
    Illinois Department finds that:
            (1) the alternate payee is not complying with the
        Department's policy or rules and regulations, or with
        the terms and conditions prescribed by the Illinois
        Department in its alternate payee registration
        agreement; or
            (2) the alternate payee has failed to keep or make
        available for inspection, audit, or copying, after
        receiving a written request from the Illinois
        Department, such records regarding payments claimed as
        an alternate payee; or
            (3) the alternate payee has failed to furnish any
        information requested by the Illinois Department
        regarding payments claimed as an alternate payee; or
            (4) the alternate payee has knowingly made, or
        caused to be made, any false statement or
        representation of a material fact in connection with
        the administration of the Illinois Medical Assistance
        Program; or
            (5) the alternate payee, a person with management
        responsibility for an alternate payee, an officer or
        person owning, either directly or indirectly, 5% or
        more of the shares of stock or other evidences of
        ownership in a corporate alternate payee, or a partner
        in a partnership which is an alternate payee:
                (a) was previously terminated, suspended, or
            excluded from participation as a vendor in the
            Illinois Medical Assistance Program, or was
            previously revoked as an alternate payee in the
            Illinois Medical Assistance Program, or was
            terminated, suspended, or excluded from
            participation as a vendor in a medical assistance
            program in another state that is of the same kind
            as the program of medical assistance provided
            under Article V of this Code; or
                (b) was a person with management
            responsibility for a vendor previously terminated,
            suspended, or excluded from participation as a
            vendor in the Illinois Medical Assistance Program,
            or was previously revoked as an alternate payee in
            the Illinois Medical Assistance Program, or was
            terminated, suspended, or excluded from
            participation as a vendor in a medical assistance
            program in another state that is of the same kind
            as the program of medical assistance provided
            under Article V of this Code, during the time of
            conduct which was the basis for that vendor's
            termination, suspension, or exclusion or alternate
            payee's revocation; or
                (c) was an officer, or person owning, either
            directly or indirectly, 5% or more of the shares of
            stock or other evidences of ownership in a
            corporate vendor previously terminated, suspended,
            or excluded from participation as a vendor in the
            Illinois Medical Assistance Program, or was
            previously revoked as an alternate payee in the
            Illinois Medical Assistance Program, or was
            terminated, suspended, or excluded from
            participation as a vendor in a medical assistance
            program in another state that is of the same kind
            as the program of medical assistance provided
            under Article V of this Code, during the time of
            conduct which was the basis for that vendor's
            termination, suspension, or exclusion; or
                (d) was an owner of a sole proprietorship or
            partner in a partnership previously terminated,
            suspended, or excluded from participation as a
            vendor in the Illinois Medical Assistance Program,
            or was previously revoked as an alternate payee in
            the Illinois Medical Assistance Program, or was
            terminated, suspended, or excluded from
            participation as a vendor in a medical assistance
            program in another state that is of the same kind
            as the program of medical assistance provided
            under Article V of this Code, during the time of
            conduct which was the basis for that vendor's
            termination, suspension, or exclusion or alternate
            payee's revocation; or
            (6) the alternate payee, a person with management
        responsibility for an alternate payee, an officer or
        person owning, either directly or indirectly, 5% or
        more of the shares of stock or other evidences of
        ownership in a corporate alternate payee, or a partner
        in a partnership which is an alternate payee:
                (a) has engaged in conduct prohibited by
            applicable federal or State law or regulation
            relating to the Illinois Medical Assistance
            Program; or
                (b) was a person with management
            responsibility for a vendor or alternate payee at
            the time that the vendor or alternate payee engaged
            in practices prohibited by applicable federal or
            State law or regulation relating to the Illinois
            Medical Assistance Program; or
                (c) was an officer, or person owning, either
            directly or indirectly, 5% or more of the shares of
            stock or other evidences of ownership in a vendor
            or alternate payee at the time such vendor or
            alternate payee engaged in practices prohibited by
            applicable federal or State law or regulation
            relating to the Illinois Medical Assistance
            Program; or
                (d) was an owner of a sole proprietorship or
            partner in a partnership which was a vendor or
            alternate payee at the time such vendor or
            alternate payee engaged in practices prohibited by
            applicable federal or State law or regulation
            relating to the Illinois Medical Assistance
            Program; or
            (7) the direct or indirect ownership of the vendor
        or alternate payee (including the ownership of a vendor
        or alternate payee that is a partner's interest in a
        vendor or alternate payee, or ownership of 5% or more
        of the shares of stock or other evidences of ownership
        in a corporate vendor or alternate payee) has been
        transferred by an individual who is terminated,
        suspended, or excluded or barred from participating as
        a vendor or is prohibited or revoked as an alternate
        payee to the individual's spouse, child, brother,
        sister, parent, grandparent, grandchild, uncle, aunt,
        niece, nephew, cousin, or relative by marriage.
    (K) The Illinois Department of Healthcare and Family
Services may withhold payments, in whole or in part, to a
provider or alternate payee where there is credible upon
receipt of evidence, received from State or federal law
enforcement or federal oversight agencies or from the results
of a preliminary Department audit and determined by the
Department to be credible, that the circumstances giving rise
to the need for a withholding of payments may involve fraud or
willful misrepresentation under the Illinois Medical
Assistance program. The Department shall by rule define what
constitutes "credible" evidence for purposes of this
subsection. The Department may withhold payments without first
notifying the provider or alternate payee of its intention to
withhold such payments. A provider or alternate payee may
request a reconsideration of payment withholding, and the
Department must grant such a request. The Department shall
state by rule a process and criteria by which a provider or
alternate payee may request full or partial release of payments
withheld under this subsection. This request may be made at any
time after the Department first withholds such payments.
        (a) The Illinois Department must send notice of its
    withholding of program payments within 5 days of taking
    such action. The notice must set forth the general
    allegations as to the nature of the withholding action, but
    need not disclose any specific information concerning its
    ongoing investigation. The notice must do all of the
    following:
            (1) State that payments are being withheld in
        accordance with this subsection.
            (2) State that the withholding is for a temporary
        period, as stated in paragraph (b) of this subsection,
        and cite the circumstances under which withholding
        will be terminated.
            (3) Specify, when appropriate, which type or types
        of Medicaid claims withholding is effective.
            (4) Inform the provider or alternate payee of the
        right to submit written evidence for reconsideration
        of the withholding by the Illinois Department.
            (5) Inform the provider or alternate payee that a
        written request may be made to the Illinois Department
        for full or partial release of withheld payments and
        that such requests may be made at any time after the
        Department first withholds such payments.
        (b) All withholding-of-payment actions under this
    subsection shall be temporary and shall not continue after
    any of the following:
            (1) The Illinois Department or the prosecuting
        authorities determine that there is insufficient
        evidence of fraud or willful misrepresentation by the
        provider or alternate payee.
            (2) Legal proceedings related to the provider's or
        alternate payee's alleged fraud, willful
        misrepresentation, violations of this Act, or
        violations of the Illinois Department's administrative
        rules are completed.
            (3) The withholding of payments for a period of 3
        years.
        (c) The Illinois Department may adopt all rules
    necessary to implement this subsection (K).
    (K-5) The Illinois Department may withhold payments, in
whole or in part, to a provider or alternate payee upon
initiation of an audit, quality of care review, investigation
when there is a credible allegation of fraud, or the provider
or alternate payee demonstrating a clear failure to cooperate
with the Illinois Department such that the circumstances give
rise to the need for a withholding of payments. As used in this
subsection, "credible allegation" is defined to include an
allegation from any source, including, but not limited to,
fraud hotline complaints, claims data mining, patterns
identified through provider audits, civil actions filed under
the False Claims Act, and law enforcement investigations. An
allegation is considered to be credible when it has indicia of
reliability. The Illinois Department may withhold payments
without first notifying the provider or alternate payee of its
intention to withhold such payments. A provider or alternate
payee may request a hearing or a reconsideration of payment
withholding, and the Illinois Department must grant such a
request. The Illinois Department shall state by rule a process
and criteria by which a provider or alternate payee may request
a hearing or a reconsideration for the full or partial release
of payments withheld under this subsection. This request may be
made at any time after the Illinois Department first withholds
such payments.
        (a) The Illinois Department must send notice of its
    withholding of program payments within 5 days of taking
    such action. The notice must set forth the general
    allegations as to the nature of the withholding action but
    need not disclose any specific information concerning its
    ongoing investigation. The notice must do all of the
    following:
            (1) State that payments are being withheld in
        accordance with this subsection.
            (2) State that the withholding is for a temporary
        period, as stated in paragraph (b) of this subsection,
        and cite the circumstances under which withholding
        will be terminated.
            (3) Specify, when appropriate, which type or types
        of claims are withheld.
            (4) Inform the provider or alternate payee of the
        right to request a hearing or a reconsideration of the
        withholding by the Illinois Department, including the
        ability to submit written evidence.
            (5) Inform the provider or alternate payee that a
        written request may be made to the Illinois Department
        for a hearing or a reconsideration for the full or
        partial release of withheld payments and that such
        requests may be made at any time after the Illinois
        Department first withholds such payments.
        (b) All withholding of payment actions under this
    subsection shall be temporary and shall not continue after
    any of the following:
            (1) The Illinois Department determines that there
        is insufficient evidence of fraud, or the provider or
        alternate payee demonstrates clear cooperation with
        the Illinois Department, as determined by the Illinois
        Department, such that the circumstances do not give
        rise to the need for withholding of payments; or
            (2) The withholding of payments has lasted for a
        period in excess of 3 years.
        (c) The Illinois Department may adopt all rules
    necessary to implement this subsection (K-5).
    (L) The Illinois Department shall establish a protocol to
enable health care providers to disclose an actual or potential
violation of this Section pursuant to a self-referral
disclosure protocol, referred to in this subsection as "the
protocol". The protocol shall include direction for health care
providers on a specific person, official, or office to whom
such disclosures shall be made. The Illinois Department shall
post information on the protocol on the Illinois Department's
public website. The Illinois Department may adopt rules
necessary to implement this subsection (L). In addition to
other factors that the Illinois Department finds appropriate,
the Illinois Department may consider a health care provider's
timely use or failure to use the protocol in considering the
provider's failure to comply with this Code.
    (M) Notwithstanding any other provision of this Code, the
Illinois Department, at its discretion, may exempt an entity
licensed under the Nursing Home Care Act and the ID/DD
Community Care Act from the provisions of subsections (A-15),
(B), and (C) of this Section if the licensed entity is in
receivership.
(Source: P.A. 94-265, eff. 1-1-06; 94-975, eff. 6-30-06.)
 
    (305 ILCS 5/12-4.38)
    Sec. 12-4.38. Special FamilyCare provisions. (a) The
Department of Healthcare and Family Services may submit to the
Comptroller, and the Comptroller is authorized to pay, on
behalf of persons enrolled in the FamilyCare Program, claims
for services rendered to an enrollee during the period
beginning October 1, 2007, and ending on the effective date of
any rules adopted to implement the provisions of this
amendatory Act of the 96th General Assembly. The authorization
for payment of claims applies only to bona fide claims for
payment for services rendered. Any claim for payment which is
authorized pursuant to the provisions of this amendatory Act of
the 96th General Assembly must adhere to all other applicable
rules, regulations, and requirements.
    (b) Each person enrolled in the FamilyCare Program as of
the effective date of this amendatory Act of the 96th General
Assembly whose income exceeds 185% of the Federal Poverty
Level, but is not more than 400% of the Federal Poverty Level,
may remain enrolled in the FamilyCare Program pursuant to this
subsection so long as that person continues to meet the
eligibility criteria established under the emergency rule at 89
Ill. Adm. Code 120 (Illinois Register Volume 31, page 15854)
filed November 7, 2007. In no case may a person continue to be
enrolled in the FamilyCare Program pursuant to this subsection
if the person's income rises above 400% of the Federal Poverty
Level or falls below 185% of the Federal Poverty Level at any
subsequent time. Nothing contained in this subsection shall
prevent an individual from enrolling in the FamilyCare Program
as authorized by paragraph 15 of Section 5-2 of this Code if he
or she otherwise qualifies under that Section.
    (c) In implementing the provisions of this amendatory Act
of the 96th General Assembly, the Department of Healthcare and
Family Services is authorized to adopt only those rules
necessary, including emergency rules. Nothing in this
amendatory Act of the 96th General Assembly permits the
Department to adopt rules or issue a decision that expands
eligibility for the FamilyCare Program to a person whose income
exceeds 185% of the Federal Poverty Level as determined from
time to time by the U.S. Department of Health and Human
Services, unless the Department is provided with express
statutory authority.
(Source: P.A. 96-20, eff. 6-30-09.)
 
    (305 ILCS 5/12-4.39)
    Sec. 12-4.39. Dental clinic grant program.
    (a) Grant program. On and after July 1, 2012, and subject
Subject to funding availability, the Department of Healthcare
and Family Services may shall administer a grant program. The
purpose of this grant program shall be to build the public
infrastructure for dental care and to make grants to local
health departments, federally qualified health clinics
(FQHCs), and rural health clinics (RHCs) for development of
comprehensive dental clinics for dental care services. The
primary purpose of these new dental clinics will be to increase
dental access for low-income and Department of Healthcare and
Family Services clients who have no dental arrangements with a
dental provider in a project's service area. The dental clinic
must be willing to accept out-of-area clients who need dental
services, including emergency services for adults and Early and
Periodic Screening, Diagnosis and Treatment (EPSDT)-referral
children. Medically Underserved Areas (MUAs) and Health
Professional Shortage Areas (HPSAs) shall receive special
priority for grants under this program.
    (b) Eligible applicants. The following entities are
eligible to apply for grants:
        (1) Local health departments.
        (2) Federally Qualified Health Centers (FQHCs).
        (3) Rural health clinics (RHCs).
    (c) Use of grant moneys. Grant moneys must be used to
support projects that develop dental services to meet the
dental health care needs of Department of Healthcare and Family
Services Dental Program clients. Grant moneys must be used for
operating expenses, including, but not limited to: insurance;
dental supplies and equipment; dental support services; and
renovation expenses. Grant moneys may not be used to offset
existing indebtedness, supplant existing funds, purchase real
property, or pay for personnel service salaries for dental
employees.
    (d) Application process. The Department shall establish
procedures for applying for dental clinic grants.
(Source: P.A. 96-67, eff. 7-23-09; 96-1000, eff. 7-2-10.)
 
    (305 ILCS 5/12-10.5)
    Sec. 12-10.5. Medical Special Purposes Trust Fund.
    (a) The Medical Special Purposes Trust Fund ("the Fund") is
created. Any grant, gift, donation, or legacy of money or
securities that the Department of Healthcare and Family
Services is authorized to receive under Section 12-4.18 or
Section 12-4.19 or any monies from any other source, and that
are is dedicated for functions connected with the
administration of any medical program administered by the
Department, shall be deposited into the Fund. All federal
moneys received by the Department as reimbursement for
disbursements authorized to be made from the Fund shall also be
deposited into the Fund. In addition, federal moneys received
on account of State expenditures made in connection with
obtaining compliance with the federal Health Insurance
Portability and Accountability Act (HIPAA) shall be deposited
into the Fund.
    (b) No moneys received from a service provider or a
governmental or private entity that is enrolled with the
Department as a provider of medical services shall be deposited
into the Fund.
    (c) Disbursements may be made from the Fund for the
purposes connected with the grants, gifts, donations, or
legacies, or other monies deposited into the Fund, including,
but not limited to, medical quality assessment projects,
eligibility population studies, medical information systems
evaluations, and other administrative functions that assist
the Department in fulfilling its health care mission under any
medical program administered by the Department.
(Source: P.A. 97-48, eff. 6-28-11.)
 
    (305 ILCS 5/12-13.1)
    Sec. 12-13.1. Inspector General.
    (a) The Governor shall appoint, and the Senate shall
confirm, an Inspector General who shall function within the
Illinois Department of Public Aid (now Healthcare and Family
Services) and report to the Governor. The term of the Inspector
General shall expire on the third Monday of January, 1997 and
every 4 years thereafter.
    (b) In order to prevent, detect, and eliminate fraud,
waste, abuse, mismanagement, and misconduct, the Inspector
General shall oversee the Department of Healthcare and Family
Services' integrity functions, which include, but are not
limited to, the following:
        (1) Investigation of misconduct by employees, vendors,
    contractors and medical providers, except for allegations
    of violations of the State Officials and Employees Ethics
    Act which shall be referred to the Office of the Governor's
    Executive Inspector General for investigation.
        (2) Prepayment and post-payment audits Audits of
    medical providers related to ensuring that appropriate
    payments are made for services rendered and to the
    prevention and recovery of overpayments.
        (3) Monitoring of quality assurance programs
    administered by the Department of Healthcare and Family
    Services generally related to the medical assistance
    program and specifically related to any managed care
    program.
        (4) Quality control measurements of the programs
    administered by the Department of Healthcare and Family
    Services.
        (5) Investigations of fraud or intentional program
    violations committed by clients of the Department of
    Healthcare and Family Services.
        (6) Actions initiated against contractors, vendors, or
    medical providers for any of the following reasons:
            (A) Violations of the medical assistance program.
            (B) Sanctions against providers brought in
        conjunction with the Department of Public Health or the
        Department of Human Services (as successor to the
        Department of Mental Health and Developmental
        Disabilities).
            (C) Recoveries of assessments against hospitals
        and long-term care facilities.
            (D) Sanctions mandated by the United States
        Department of Health and Human Services against
        medical providers.
            (E) Violations of contracts related to any
        programs administered by the Department of Healthcare
        and Family Services managed care programs.
        (7) Representation of the Department of Healthcare and
    Family Services at hearings with the Illinois Department of
    Financial and Professional Regulation in actions taken
    against professional licenses held by persons who are in
    violation of orders for child support payments.
    (b-5) At the request of the Secretary of Human Services,
the Inspector General shall, in relation to any function
performed by the Department of Human Services as successor to
the Department of Public Aid, exercise one or more of the
powers provided under this Section as if those powers related
to the Department of Human Services; in such matters, the
Inspector General shall report his or her findings to the
Secretary of Human Services.
    (c) Notwithstanding, and in addition to, any other
provision of law, the The Inspector General shall have access
to all information, personnel and facilities of the Department
of Healthcare and Family Services and the Department of Human
Services (as successor to the Department of Public Aid), their
employees, vendors, contractors and medical providers and any
federal, State or local governmental agency that are necessary
to perform the duties of the Office as directly related to
public assistance programs administered by those departments.
No medical provider shall be compelled, however, to provide
individual medical records of patients who are not clients of
the programs administered by the Department of Healthcare and
Family Services Medical Assistance Program. State and local
governmental agencies are authorized and directed to provide
the requested information, assistance or cooperation.
    For purposes of enhanced program integrity functions and
oversight, and to the extent consistent with applicable
information and privacy, security, and disclosure laws, State
agencies and departments shall provide the Office of Inspector
General access to confidential and other information and data,
and the Inspector General is authorized to enter into
agreements with appropriate federal agencies and departments
to secure similar data. This includes, but is not limited to,
information pertaining to: licensure; certification; earnings;
immigration status; citizenship; wage reporting; unearned and
earned income; pension income; employment; supplemental
security income; social security numbers; National Provider
Identifier (NPI) numbers; the National Practitioner Data Bank
(NPDB); program and agency exclusions; taxpayer identification
numbers; tax delinquency; corporate information; and death
records.
    The Inspector General shall enter into agreements with
State agencies and departments, and is authorized to enter into
agreements with federal agencies and departments, under which
such agencies and departments shall share data necessary for
medical assistance program integrity functions and oversight.
The Inspector General shall enter into agreements with State
agencies and departments, and is authorized to enter into
agreements with federal agencies and departments, under which
such agencies shall share data necessary for recipient and
vendor screening, review, and investigation, including but not
limited to vendor payment and recipient eligibility
verification. The Inspector General shall develop, in
cooperation with other State and federal agencies and
departments, and in compliance with applicable federal laws and
regulations, appropriate and effective methods to share such
data. The Inspector General shall enter into agreements with
State agencies and departments, and is authorized to enter into
agreements with federal agencies and departments, including,
but not limited to: the Secretary of State; the Department of
Revenue; the Department of Public Health; the Department of
Human Services; and the Department of Financial and
Professional Regulation.
    The Inspector General shall have the authority to deny
payment, prevent overpayments, and recover overpayments.
    The Inspector General shall have the authority to deny or
suspend payment to, and deny, terminate, or suspend the
eligibility of, any vendor who fails to grant the Inspector
General timely access to full and complete records, including
records of recipients under the medical assistance program for
the most recent 6 years, in accordance with Section 140.28 of
Title 89 of the Illinois Administrative Code, and other
information for the purpose of audits, investigations, or other
program integrity functions, after reasonable written request
by the Inspector General.
    (d) The Inspector General shall serve as the Department of
Healthcare and Family Services' primary liaison with law
enforcement, investigatory and prosecutorial agencies,
including but not limited to the following:
        (1) The Department of State Police.
        (2) The Federal Bureau of Investigation and other
    federal law enforcement agencies.
        (3) The various Inspectors General of federal agencies
    overseeing the programs administered by the Department of
    Healthcare and Family Services.
        (4) The various Inspectors General of any other State
    agencies with responsibilities for portions of programs
    primarily administered by the Department of Healthcare and
    Family Services.
        (5) The Offices of the several United States Attorneys
    in Illinois.
        (6) The several State's Attorneys.
        (7) The offices of the Centers for Medicare and
    Medicaid Services that administer the Medicare and
    Medicaid integrity programs.
    The Inspector General shall meet on a regular basis with
these entities to share information regarding possible
misconduct by any persons or entities involved with the public
aid programs administered by the Department of Healthcare and
Family Services.
    (e) All investigations conducted by the Inspector General
shall be conducted in a manner that ensures the preservation of
evidence for use in criminal prosecutions. If the Inspector
General determines that a possible criminal act relating to
fraud in the provision or administration of the medical
assistance program has been committed, the Inspector General
shall immediately notify the Medicaid Fraud Control Unit. If
the Inspector General determines that a possible criminal act
has been committed within the jurisdiction of the Office, the
Inspector General may request the special expertise of the
Department of State Police. The Inspector General may present
for prosecution the findings of any criminal investigation to
the Office of the Attorney General, the Offices of the several
United States Attorneys in Illinois or the several State's
Attorneys.
    (f) To carry out his or her duties as described in this
Section, the Inspector General and his or her designees shall
have the power to compel by subpoena the attendance and
testimony of witnesses and the production of books, electronic
records and papers as directly related to public assistance
programs administered by the Department of Healthcare and
Family Services or the Department of Human Services (as
successor to the Department of Public Aid). No medical provider
shall be compelled, however, to provide individual medical
records of patients who are not clients of the Medical
Assistance Program.
    (g) The Inspector General shall report all convictions,
terminations, and suspensions taken against vendors,
contractors and medical providers to the Department of
Healthcare and Family Services and to any agency responsible
for licensing or regulating those persons or entities.
    (h) The Inspector General shall make annual reports,
findings, and recommendations regarding the Office's
investigations into reports of fraud, waste, abuse,
mismanagement, or misconduct relating to any public aid
programs administered by the Department of Healthcare and
Family Services or the Department of Human Services (as
successor to the Department of Public Aid) to the General
Assembly and the Governor. These reports shall include, but not
be limited to, the following information:
        (1) Aggregate provider billing and payment
    information, including the number of providers at various
    Medicaid earning levels.
        (2) The number of audits of the medical assistance
    program and the dollar savings resulting from those audits.
        (3) The number of prescriptions rejected annually
    under the Department of Healthcare and Family Services'
    Refill Too Soon program and the dollar savings resulting
    from that program.
        (4) Provider sanctions, in the aggregate, including
    terminations and suspensions.
        (5) A detailed summary of the investigations
    undertaken in the previous fiscal year. These summaries
    shall comply with all laws and rules regarding maintaining
    confidentiality in the public aid programs.
    (i) Nothing in this Section shall limit investigations by
the Department of Healthcare and Family Services or the
Department of Human Services that may otherwise be required by
law or that may be necessary in their capacity as the central
administrative authorities responsible for administration of
their agency's public aid programs in this State.
    (j) The Inspector General may issue shields or other
distinctive identification to his or her employees not
exercising the powers of a peace officer if the Inspector
General determines that a shield or distinctive identification
is needed by an employee to carry out his or her
responsibilities.
(Source: P.A. 95-331, eff. 8-21-07; 96-555, eff. 8-18-09;
96-1316, eff. 1-1-11.)
 
    (305 ILCS 5/14-8)  (from Ch. 23, par. 14-8)
    Sec. 14-8. Disbursements to Hospitals.
    (a) For inpatient hospital services rendered on and after
September 1, 1991, the Illinois Department shall reimburse
hospitals for inpatient services at an inpatient payment rate
calculated for each hospital based upon the Medicare
Prospective Payment System as set forth in Sections 1886(b),
(d), (g), and (h) of the federal Social Security Act, and the
regulations, policies, and procedures promulgated thereunder,
except as modified by this Section. Payment rates for inpatient
hospital services rendered on or after September 1, 1991 and on
or before September 30, 1992 shall be calculated using the
Medicare Prospective Payment rates in effect on September 1,
1991. Payment rates for inpatient hospital services rendered on
or after October 1, 1992 and on or before March 31, 1994 shall
be calculated using the Medicare Prospective Payment rates in
effect on September 1, 1992. Payment rates for inpatient
hospital services rendered on or after April 1, 1994 shall be
calculated using the Medicare Prospective Payment rates
(including the Medicare grouping methodology and weighting
factors as adjusted pursuant to paragraph (1) of this
subsection) in effect 90 days prior to the date of admission.
For services rendered on or after July 1, 1995, the
reimbursement methodology implemented under this subsection
shall not include those costs referred to in Sections
1886(d)(5)(B) and 1886(h) of the Social Security Act. The
additional payment amounts required under Section
1886(d)(5)(F) of the Social Security Act, for hospitals serving
a disproportionate share of low-income or indigent patients,
are not required under this Section. For hospital inpatient
services rendered on or after July 1, 1995, the Illinois
Department shall reimburse hospitals using the relative
weighting factors and the base payment rates calculated for
each hospital that were in effect on June 30, 1995, less the
portion of such rates attributed by the Illinois Department to
the cost of medical education.
        (1) The weighting factors established under Section
    1886(d)(4) of the Social Security Act shall not be used in
    the reimbursement system established under this Section.
    Rather, the Illinois Department shall establish by rule
    Medicaid weighting factors to be used in the reimbursement
    system established under this Section.
        (2) The Illinois Department shall define by rule those
    hospitals or distinct parts of hospitals that shall be
    exempt from the reimbursement system established under
    this Section. In defining such hospitals, the Illinois
    Department shall take into consideration those hospitals
    exempt from the Medicare Prospective Payment System as of
    September 1, 1991. For hospitals defined as exempt under
    this subsection, the Illinois Department shall by rule
    establish a reimbursement system for payment of inpatient
    hospital services rendered on and after September 1, 1991.
    For all hospitals that are children's hospitals as defined
    in Section 5-5.02 of this Code, the reimbursement
    methodology shall, through June 30, 1992, net of all
    applicable fees, at least equal each children's hospital
    1990 ICARE payment rates, indexed to the current year by
    application of the DRI hospital cost index from 1989 to the
    year in which payments are made. Excepting county providers
    as defined in Article XV of this Code, hospitals licensed
    under the University of Illinois Hospital Act, and
    facilities operated by the Department of Mental Health and
    Developmental Disabilities (or its successor, the
    Department of Human Services) for hospital inpatient
    services rendered on or after July 1, 1995, the Illinois
    Department shall reimburse children's hospitals, as
    defined in 89 Illinois Administrative Code Section
    149.50(c)(3), at the rates in effect on June 30, 1995, and
    shall reimburse all other hospitals at the rates in effect
    on June 30, 1995, less the portion of such rates attributed
    by the Illinois Department to the cost of medical
    education. For inpatient hospital services provided on or
    after August 1, 1998, the Illinois Department may establish
    by rule a means of adjusting the rates of children's
    hospitals, as defined in 89 Illinois Administrative Code
    Section 149.50(c)(3), that did not meet that definition on
    June 30, 1995, in order for the inpatient hospital rates of
    such hospitals to take into account the average inpatient
    hospital rates of those children's hospitals that did meet
    the definition of children's hospitals on June 30, 1995.
        (3) (Blank)
        (4) Notwithstanding any other provision of this
    Section, hospitals that on August 31, 1991, have a contract
    with the Illinois Department under Section 3-4 of the
    Illinois Health Finance Reform Act may elect to continue to
    be reimbursed at rates stated in such contracts for general
    and specialty care.
        (5) In addition to any payments made under this
    subsection (a), the Illinois Department shall make the
    adjustment payments required by Section 5-5.02 of this
    Code; provided, that in the case of any hospital reimbursed
    under a per case methodology, the Illinois Department shall
    add an amount equal to the product of the hospital's
    average length of stay, less one day, multiplied by 20, for
    inpatient hospital services rendered on or after September
    1, 1991 and on or before September 30, 1992.
    (b) (Blank)
    (b-5) Excepting county providers as defined in Article XV
of this Code, hospitals licensed under the University of
Illinois Hospital Act, and facilities operated by the Illinois
Department of Mental Health and Developmental Disabilities (or
its successor, the Department of Human Services), for
outpatient services rendered on or after July 1, 1995 and
before July 1, 1998 the Illinois Department shall reimburse
children's hospitals, as defined in the Illinois
Administrative Code Section 149.50(c)(3), at the rates in
effect on June 30, 1995, less that portion of such rates
attributed by the Illinois Department to the outpatient
indigent volume adjustment and shall reimburse all other
hospitals at the rates in effect on June 30, 1995, less the
portions of such rates attributed by the Illinois Department to
the cost of medical education and attributed by the Illinois
Department to the outpatient indigent volume adjustment. For
outpatient services provided on or after July 1, 1998,
reimbursement rates shall be established by rule.
    (c) In addition to any other payments under this Code, the
Illinois Department shall develop a hospital disproportionate
share reimbursement methodology that, effective July 1, 1991,
through September 30, 1992, shall reimburse hospitals
sufficiently to expend the fee monies described in subsection
(b) of Section 14-3 of this Code and the federal matching funds
received by the Illinois Department as a result of expenditures
made by the Illinois Department as required by this subsection
(c) and Section 14-2 that are attributable to fee monies
deposited in the Fund, less amounts applied to adjustment
payments under Section 5-5.02.
    (d) Critical Care Access Payments.
        (1) In addition to any other payments made under this
    Code, the Illinois Department shall develop a
    reimbursement methodology that shall reimburse Critical
    Care Access Hospitals for the specialized services that
    qualify them as Critical Care Access Hospitals. No
    adjustment payments shall be made under this subsection on
    or after July 1, 1995.
        (2) "Critical Care Access Hospitals" includes, but is
    not limited to, hospitals that meet at least one of the
    following criteria:
            (A) Hospitals located outside of a metropolitan
        statistical area that are designated as Level II
        Perinatal Centers and that provide a disproportionate
        share of perinatal services to recipients; or
            (B) Hospitals that are designated as Level I Trauma
        Centers (adult or pediatric) and certain Level II
        Trauma Centers as determined by the Illinois
        Department; or
            (C) Hospitals located outside of a metropolitan
        statistical area and that provide a disproportionate
        share of obstetrical services to recipients.
    (e) Inpatient high volume adjustment. For hospital
inpatient services, effective with rate periods beginning on or
after October 1, 1993, in addition to rates paid for inpatient
services by the Illinois Department, the Illinois Department
shall make adjustment payments for inpatient services
furnished by Medicaid high volume hospitals. The Illinois
Department shall establish by rule criteria for qualifying as a
Medicaid high volume hospital and shall establish by rule a
reimbursement methodology for calculating these adjustment
payments to Medicaid high volume hospitals. No adjustment
payment shall be made under this subsection for services
rendered on or after July 1, 1995.
    (f) The Illinois Department shall modify its current rules
governing adjustment payments for targeted access, critical
care access, and uncompensated care to classify those
adjustment payments as not being payments to disproportionate
share hospitals under Title XIX of the federal Social Security
Act. Rules adopted under this subsection shall not be effective
with respect to services rendered on or after July 1, 1995. The
Illinois Department has no obligation to adopt or implement any
rules or make any payments under this subsection for services
rendered on or after July 1, 1995.
    (f-5) The State recognizes that adjustment payments to
hospitals providing certain services or incurring certain
costs may be necessary to assure that recipients of medical
assistance have adequate access to necessary medical services.
These adjustments include payments for teaching costs and
uncompensated care, trauma center payments, rehabilitation
hospital payments, perinatal center payments, obstetrical care
payments, targeted access payments, Medicaid high volume
payments, and outpatient indigent volume payments. On or before
April 1, 1995, the Illinois Department shall issue
recommendations regarding (i) reimbursement mechanisms or
adjustment payments to reflect these costs and services,
including methods by which the payments may be calculated and
the method by which the payments may be financed, and (ii)
reimbursement mechanisms or adjustment payments to reflect
costs and services of federally qualified health centers with
respect to recipients of medical assistance.
    (g) If one or more hospitals file suit in any court
challenging any part of this Article XIV, payments to hospitals
under this Article XIV shall be made only to the extent that
sufficient monies are available in the Fund and only to the
extent that any monies in the Fund are not prohibited from
disbursement under any order of the court.
    (h) Payments under the disbursement methodology described
in this Section are subject to approval by the federal
government in an appropriate State plan amendment.
    (i) The Illinois Department may by rule establish criteria
for and develop methodologies for adjustment payments to
hospitals participating under this Article.
    (j) Hospital Residing Long Term Care Services. In addition
to any other payments made under this Code, the Illinois
Department may by rule establish criteria and develop
methodologies for payments to hospitals for Hospital Residing
Long Term Care Services.
    (k) Critical Access Hospital outpatient payments. In
addition to any other payments authorized under this Code, the
Illinois Department shall reimburse critical access hospitals,
as designated by the Illinois Department of Public Health in
accordance with 42 CFR 485, Subpart F, for outpatient services
at an amount that is no less than the cost of providing such
services, based on Medicare cost principles. Payments under
this subsection shall be subject to appropriation.
    (l) On and after July 1, 2012, the Department shall reduce
any rate of reimbursement for services or other payments or
alter any methodologies authorized by this Code to reduce any
rate of reimbursement for services or other payments in
accordance with Section 5-5e.
(Source: P.A. 96-1382, eff. 1-1-11.)
 
    (305 ILCS 5/14-11 new)
    Sec. 14-11. Hospital payment reform.
    (a) The Department may, by rule, implement the All Patient
Refined Diagnosis Related Groups (APR-DRG) payment system for
inpatient services provided on or after July 1, 2013, in a
manner consistent with the actions authorized in this Section.
    (b) On or before October 1, 2012 and through June 30, 2013,
the Department shall begin testing the APR-DRG system. During
the testing period the Department shall process and price
inpatient services using the APR-DRG system; however, actual
payments for those inpatient services shall be made using the
current reimbursement system. During the testing period, the
Department, in collaboration with the statewide representative
of hospitals, shall provide information and technical
assistance to hospitals to encourage and facilitate their
transition to the APR-DRG system.
    (c) The Department may, by rule, implement the Enhanced
Ambulatory Procedure Grouping (EAPG) system for outpatient
services provided on or after January 1, 2014, in a manner
consistent with the actions authorized in this Section. On or
before January 1, 2013 and through December 31, 2013, the
Department shall begin testing the EAPG system. During the
testing period the Department shall process and price
outpatient services using the EAPG system; however, actual
payments for those outpatient services shall be made using the
current reimbursement system. During the testing period, the
Department, in collaboration with the statewide representative
of hospitals, shall provide information and technical
assistance to hospitals to encourage and facilitate their
transition to the EAPG system.
    (d) The Department in consultation with the current
hospital technical advisory group shall review the test claims
for inpatient and outpatient services at least monthly,
including the estimated impact on hospitals, and, in developing
the rules, policies, and procedures to implement the new
payment systems, shall consider at least the following issues:
        (1) The use of national relative weights provided by
    the vendor of the APR-DRG system, adjusted to reflect
    characteristics of the Illinois Medical Assistance
    population.
        (2) An updated outlier payment methodology based on
    current data and consistent with the APR-DRG system.
        (3) The use of policy adjusters to enhance payments to
    hospitals treating a high percentage of individuals
    covered by the Medical Assistance program and uninsured
    patients.
        (4) Reimbursement for inpatient specialty services
    such as psychiatric, rehabilitation, and long-term acute
    care using updated per diem rates that account for service
    acuity.
        (5) The creation of one or more transition funding
    pools to preserve access to care and to ensure financial
    stability as hospitals transition to the new payment
    system.
        (6) Whether, beginning July 1, 2014, some of the static
    adjustment payments financed by General Revenue funds
    should be used as part of the base payment system,
    including as policy adjusters to recognize the additional
    costs of certain services, such as pediatric or neonatal,
    or providers, such as trauma centers, Critical Access
    Hospitals, or high Medicaid hospitals, or for services to
    uninsured patients.
    (e) The Department shall provide the association
representing the majority of hospitals in Illinois, as the
statewide representative of the hospital community, with a
monthly file of claims adjudicated under the test system for
the purpose of review and analysis as part of the collaboration
between the State and the hospital community. The file shall
consist of a de-identified extract compliant with the Health
Insurance Portability and Accountability Act (HIPAA).
    (f) The current hospital technical advisory group shall
make recommendations for changes during the testing period and
recommendations for changes prior to the effective dates of the
new payment systems. The Department shall draft administrative
rules to implement the new payment systems and provide them to
the technical advisory group at least 90 days prior to the
proposed effective dates of the new payment systems.
    (g) The payments to hospitals financed by the current
hospital assessment, authorized under Article V-A of this Code,
are scheduled to sunset on June 30, 2014. The continuation of
or revisions to the hospital assessment program shall take into
consideration the impact on hospitals and access to care as a
result of the changes to the hospital payment system.
    (h) Beginning July 1, 2014, the Department may transition
current General Revenue funded supplemental payments into the
claims based system over a period of no less than 2 years from
the implementation date of the new payment systems and no more
than 4 years from the implementation date of the new payment
systems, provided however that the Department may adopt, by
rule, supplemental payments to help ensure access to care in a
geographic area or to help ensure access to specialty services.
For any supplemental payments that are adopted that are based
on historic data, the data shall be no older than 3 years and
the supplemental payment shall be effective for no longer than
2 years before requiring the data to be updated.
    (i) Any payments authorized under 89 Illinois
Administrative Code 148 set to expire in State fiscal year 2012
and that were paid out to hospitals in State fiscal year 2012
shall remain in effect as long as the assessment imposed by
Section 5A-2 is in effect.
    (j) Subsections (a) and (c) of this Section shall remain
operative unless the Auditor General has reported that: (i) the
Department has not undertaken the required actions listed in
the report required by subsection (a) of Section 2-20 of the
Illinois State Auditing Act; or (ii) the Department has failed
to comply with the reporting requirements of Section 2-20 of
the Illinois State Auditing Act.
    (k) Subsections (a) and (c) of this Section shall not be
operative until final federal approval by the Centers for
Medicare and Medicaid Services of the U.S. Department of Health
and Human Services and implementation of all of the payments
and assessments in Article V-A in its form as of the effective
date of this amendatory Act of the 97th General Assembly or as
it may be amended.
 
    (305 ILCS 5/15-1)  (from Ch. 23, par. 15-1)
    Sec. 15-1. Definitions. As used in this Article, unless the
context requires otherwise:
    (a) (Blank). "Base amount" means $108,800,000 multiplied
by a fraction, the numerator of which is the number of days
represented by the payments in question and the denominator of
which is 365.
    (a-5) "County provider" means a health care provider that
is, or is operated by, a county with a population greater than
3,000,000.
    (b) "Fund" means the County Provider Trust Fund.
    (c) "Hospital" or "County hospital" means a hospital, as
defined in Section 14-1 of this Code, which is a county
hospital located in a county of over 3,000,000 population.
(Source: P.A. 87-13; 88-85; 88-554, eff. 7-26-94.)
 
    Section 85. The Pediatric Palliative Care Act is amended by
adding Section 3 as follows:
 
    (305 ILCS 60/3 new)
    Sec. 3. Act inoperative. Notwithstanding any other
provision of law, this Act is inoperative on and after July 1,
2012.
 
    (305 ILCS 5/5-5.4a rep.)
    (305 ILCS 5/5-5.4c rep.)
    (305 ILCS 5/12-4.36 rep.)
    Section 88. The Illinois Public Aid Code is amended by
repealing Sections 5-5.4a, 5-5.4c, and 12-4.36.
 
    Section 90. The Senior Citizens and Disabled Persons
Property Tax Relief and Pharmaceutical Assistance Act is
amended by changing the title of the Act and Sections 1, 1.5,
2, 3.05a, 3.10, 4, 4.05, 5, 6, 7, 8, 9, 12, and 13 as follows:
 
    (320 ILCS 25/Act title)
An Act in relation to the payment of grants to enable the
elderly and the disabled to acquire or retain private housing
and to acquire prescription drugs.
 
    (320 ILCS 25/1)  (from Ch. 67 1/2, par. 401)
    Sec. 1. Short title; common name. This Article shall be
known and may be cited as the Senior Citizens and Disabled
Persons Property Tax Relief and Pharmaceutical Assistance Act.
Common references to the "Circuit Breaker Act" mean this
Article. As used in this Article, "this Act" means this
Article.
(Source: P.A. 96-804, eff. 1-1-10.)
 
    (320 ILCS 25/1.5)
    Sec. 1.5. Implementation of Executive Order No. 3 of 2004;
termination of the Illinois Senior Citizens and Disabled
Persons Pharmaceutical Assistance Program. Executive Order No.
3 of 2004, in part, provided for the transfer of the programs
under this Act from the Department of Revenue to the Department
on Aging and the Department of Healthcare and Family Services.
It is the purpose of this amendatory Act of the 96th General
Assembly to conform this Act and certain related provisions of
other statutes to that Executive Order. This amendatory Act of
the 96th General Assembly also makes other substantive changes
to this Act.
    It is the purpose of this amendatory Act of the 97th
General Assembly to terminate the Illinois Senior Citizens and
Disabled Persons Pharmaceutical Assistance Program on July 1,
2012.
(Source: P.A. 96-804, eff. 1-1-10.)
 
    (320 ILCS 25/2)  (from Ch. 67 1/2, par. 402)
    Sec. 2. Purpose. The purpose of this Act is to provide
incentives to the senior citizens and disabled persons of this
State to acquire and retain private housing of their choice and
at the same time to relieve those citizens from the burdens of
extraordinary property taxes and rising drug costs against
their increasingly restricted earning power, and thereby to
reduce the requirements for public housing in this State.
(Source: P.A. 96-804, eff. 1-1-10.)
 
    (320 ILCS 25/3.05a)
    Sec. 3.05a. Additional resident. "Additional resident"
means a person who (i) is living in the same residence with a
claimant for the claim year and at the time of filing the
claim, (ii) is not the spouse of the claimant, (iii) does not
file a separate claim under this Act for the same period, and
(iv) receives more than half of his or her total financial
support for that claim year from the household. Prior to July
1, 2012, an An additional resident who meets qualifications may
receive pharmaceutical assistance based on a claimant's
application.
(Source: P.A. 96-804, eff. 1-1-10.)
 
    (320 ILCS 25/3.10)  (from Ch. 67 1/2, par. 403.10)
    Sec. 3.10. Regulations. "Regulations" includes both rules
promulgated and forms prescribed by the applicable Department.
In this Act, references to the rules of the Department on Aging
or the Department of Healthcare and Family Services, in effect
prior to July 1, 2012, shall be deemed to include, in
appropriate cases, the corresponding rules adopted by the
Department of Revenue, to the extent that those rules continue
in force under Executive Order No. 3 of 2004.
(Source: P.A. 96-804, eff. 1-1-10.)
 
    (320 ILCS 25/4)  (from Ch. 67 1/2, par. 404)
    Sec. 4. Amount of Grant.
    (a) In general. Any individual 65 years or older or any
individual who will become 65 years old during the calendar
year in which a claim is filed, and any surviving spouse of
such a claimant, who at the time of death received or was
entitled to receive a grant pursuant to this Section, which
surviving spouse will become 65 years of age within the 24
months immediately following the death of such claimant and
which surviving spouse but for his or her age is otherwise
qualified to receive a grant pursuant to this Section, and any
disabled person whose annual household income is less than the
income eligibility limitation, as defined in subsection (a-5)
and whose household is liable for payment of property taxes
accrued or has paid rent constituting property taxes accrued
and is domiciled in this State at the time he or she files his
or her claim is entitled to claim a grant under this Act. With
respect to claims filed by individuals who will become 65 years
old during the calendar year in which a claim is filed, the
amount of any grant to which that household is entitled shall
be an amount equal to 1/12 of the amount to which the claimant
would otherwise be entitled as provided in this Section,
multiplied by the number of months in which the claimant was 65
in the calendar year in which the claim is filed.
    (a-5) Income eligibility limitation. For purposes of this
Section, "income eligibility limitation" means an amount for
grant years 2008 and thereafter:
        (1) less than $22,218 for a household containing one
    person;
        (2) less than $29,480 for a household containing 2
    persons; or
        (3) less than $36,740 for a household containing 3 or
    more persons.
    For 2009 claim year applications submitted during calendar
year 2010, a household must have annual household income of
less than $27,610 for a household containing one person; less
than $36,635 for a household containing 2 persons; or less than
$45,657 for a household containing 3 or more persons.
    The Department on Aging may adopt rules such that on
January 1, 2011, and thereafter, the foregoing household income
eligibility limits may be changed to reflect the annual cost of
living adjustment in Social Security and Supplemental Security
Income benefits that are applicable to the year for which those
benefits are being reported as income on an application.
    If a person files as a surviving spouse, then only his or
her income shall be counted in determining his or her household
income.
    (b) Limitation. Except as otherwise provided in
subsections (a) and (f) of this Section, the maximum amount of
grant which a claimant is entitled to claim is the amount by
which the property taxes accrued which were paid or payable
during the last preceding tax year or rent constituting
property taxes accrued upon the claimant's residence for the
last preceding taxable year exceeds 3 1/2% of the claimant's
household income for that year but in no event is the grant to
exceed (i) $700 less 4.5% of household income for that year for
those with a household income of $14,000 or less or (ii) $70 if
household income for that year is more than $14,000.
    (c) Public aid recipients. If household income in one or
more months during a year includes cash assistance in excess of
$55 per month from the Department of Healthcare and Family
Services or the Department of Human Services (acting as
successor to the Department of Public Aid under the Department
of Human Services Act) which was determined under regulations
of that Department on a measure of need that included an
allowance for actual rent or property taxes paid by the
recipient of that assistance, the amount of grant to which that
household is entitled, except as otherwise provided in
subsection (a), shall be the product of (1) the maximum amount
computed as specified in subsection (b) of this Section and (2)
the ratio of the number of months in which household income did
not include such cash assistance over $55 to the number twelve.
If household income did not include such cash assistance over
$55 for any months during the year, the amount of the grant to
which the household is entitled shall be the maximum amount
computed as specified in subsection (b) of this Section. For
purposes of this paragraph (c), "cash assistance" does not
include any amount received under the federal Supplemental
Security Income (SSI) program.
    (d) Joint ownership. If title to the residence is held
jointly by the claimant with a person who is not a member of
his or her household, the amount of property taxes accrued used
in computing the amount of grant to which he or she is entitled
shall be the same percentage of property taxes accrued as is
the percentage of ownership held by the claimant in the
residence.
    (e) More than one residence. If a claimant has occupied
more than one residence in the taxable year, he or she may
claim only one residence for any part of a month. In the case
of property taxes accrued, he or she shall prorate 1/12 of the
total property taxes accrued on his or her residence to each
month that he or she owned and occupied that residence; and, in
the case of rent constituting property taxes accrued, shall
prorate each month's rent payments to the residence actually
occupied during that month.
    (f) (Blank).
    (g) Effective January 1, 2006, there is hereby established
a program of pharmaceutical assistance to the aged and
disabled, entitled the Illinois Seniors and Disabled Drug
Coverage Program, which shall be administered by the Department
of Healthcare and Family Services and the Department on Aging
in accordance with this subsection, to consist of coverage of
specified prescription drugs on behalf of beneficiaries of the
program as set forth in this subsection. Notwithstanding any
provisions of this Act to the contrary, on and after July 1,
2012, pharmaceutical assistance under this Act shall no longer
be provided, and on July 1, 2012 the Illinois Senior Citizens
and Disabled Persons Pharmaceutical Assistance Program shall
terminate. The following provisions that concern the Illinois
Senior Citizens and Disabled Persons Pharmaceutical Assistance
Program shall continue to apply on and after July 1, 2012 to
the extent necessary to pursue any actions authorized by
subsection (d) of Section 9 of this Act with respect to acts
which took place prior to July 1, 2012.
    To become a beneficiary under the program established under
this subsection, a person must:
        (1) be (i) 65 years of age or older or (ii) disabled;
    and
        (2) be domiciled in this State; and
        (3) enroll with a qualified Medicare Part D
    Prescription Drug Plan if eligible and apply for all
    available subsidies under Medicare Part D; and
        (4) for the 2006 and 2007 claim years, have a maximum
    household income of (i) less than $21,218 for a household
    containing one person, (ii) less than $28,480 for a
    household containing 2 persons, or (iii) less than $35,740
    for a household containing 3 or more persons; and
        (5) for the 2008 claim year, have a maximum household
    income of (i) less than $22,218 for a household containing
    one person, (ii) $29,480 for a household containing 2
    persons, or (iii) $36,740 for a household containing 3 or
    more persons; and
        (6) for 2009 claim year applications submitted during
    calendar year 2010, have annual household income of less
    than (i) $27,610 for a household containing one person;
    (ii) less than $36,635 for a household containing 2
    persons; or (iii) less than $45,657 for a household
    containing 3 or more persons; and
        (7) as of September 1, 2011, have a maximum household
    income at or below 200% of the federal poverty level.
    All individuals enrolled as of December 31, 2005, in the
pharmaceutical assistance program operated pursuant to
subsection (f) of this Section and all individuals enrolled as
of December 31, 2005, in the SeniorCare Medicaid waiver program
operated pursuant to Section 5-5.12a of the Illinois Public Aid
Code shall be automatically enrolled in the program established
by this subsection for the first year of operation without the
need for further application, except that they must apply for
Medicare Part D and the Low Income Subsidy under Medicare Part
D. A person enrolled in the pharmaceutical assistance program
operated pursuant to subsection (f) of this Section as of
December 31, 2005, shall not lose eligibility in future years
due only to the fact that they have not reached the age of 65.
    To the extent permitted by federal law, the Department may
act as an authorized representative of a beneficiary in order
to enroll the beneficiary in a Medicare Part D Prescription
Drug Plan if the beneficiary has failed to choose a plan and,
where possible, to enroll beneficiaries in the low-income
subsidy program under Medicare Part D or assist them in
enrolling in that program.
    Beneficiaries under the program established under this
subsection shall be divided into the following 4 eligibility
groups:
        (A) Eligibility Group 1 shall consist of beneficiaries
    who are not eligible for Medicare Part D coverage and who
    are:
            (i) disabled and under age 65; or
            (ii) age 65 or older, with incomes over 200% of the
        Federal Poverty Level; or
            (iii) age 65 or older, with incomes at or below
        200% of the Federal Poverty Level and not eligible for
        federally funded means-tested benefits due to
        immigration status.
        (B) Eligibility Group 2 shall consist of beneficiaries
    who are eligible for Medicare Part D coverage.
        (C) Eligibility Group 3 shall consist of beneficiaries
    age 65 or older, with incomes at or below 200% of the
    Federal Poverty Level, who are not barred from receiving
    federally funded means-tested benefits due to immigration
    status and are not eligible for Medicare Part D coverage.
        If the State applies and receives federal approval for
    a waiver under Title XIX of the Social Security Act,
    persons in Eligibility Group 3 shall continue to receive
    benefits through the approved waiver, and Eligibility
    Group 3 may be expanded to include disabled persons under
    age 65 with incomes under 200% of the Federal Poverty Level
    who are not eligible for Medicare and who are not barred
    from receiving federally funded means-tested benefits due
    to immigration status.
        (D) Eligibility Group 4 shall consist of beneficiaries
    who are otherwise described in Eligibility Group 2 who have
    a diagnosis of HIV or AIDS.
    The program established under this subsection shall cover
the cost of covered prescription drugs in excess of the
beneficiary cost-sharing amounts set forth in this paragraph
that are not covered by Medicare. The Department of Healthcare
and Family Services may establish by emergency rule changes in
cost-sharing necessary to conform the cost of the program to
the amounts appropriated for State fiscal year 2012 and future
fiscal years except that the 24-month limitation on the
adoption of emergency rules and the provisions of Sections
5-115 and 5-125 of the Illinois Administrative Procedure Act
shall not apply to rules adopted under this subsection (g). The
adoption of emergency rules authorized by this subsection (g)
shall be deemed to be necessary for the public interest,
safety, and welfare.
    For purposes of the program established under this
subsection, the term "covered prescription drug" has the
following meanings:
        For Eligibility Group 1, "covered prescription drug"
    means: (1) any cardiovascular agent or drug; (2) any
    insulin or other prescription drug used in the treatment of
    diabetes, including syringe and needles used to administer
    the insulin; (3) any prescription drug used in the
    treatment of arthritis; (4) any prescription drug used in
    the treatment of cancer; (5) any prescription drug used in
    the treatment of Alzheimer's disease; (6) any prescription
    drug used in the treatment of Parkinson's disease; (7) any
    prescription drug used in the treatment of glaucoma; (8)
    any prescription drug used in the treatment of lung disease
    and smoking-related illnesses; (9) any prescription drug
    used in the treatment of osteoporosis; and (10) any
    prescription drug used in the treatment of multiple
    sclerosis. The Department may add additional therapeutic
    classes by rule. The Department may adopt a preferred drug
    list within any of the classes of drugs described in items
    (1) through (10) of this paragraph. The specific drugs or
    therapeutic classes of covered prescription drugs shall be
    indicated by rule.
        For Eligibility Group 2, "covered prescription drug"
    means those drugs covered by the Medicare Part D
    Prescription Drug Plan in which the beneficiary is
    enrolled.
        For Eligibility Group 3, "covered prescription drug"
    means those drugs covered by the Medical Assistance Program
    under Article V of the Illinois Public Aid Code.
        For Eligibility Group 4, "covered prescription drug"
    means those drugs covered by the Medicare Part D
    Prescription Drug Plan in which the beneficiary is
    enrolled.
    Any person otherwise eligible for pharmaceutical
assistance under this subsection whose covered drugs are
covered by any public program is ineligible for assistance
under this subsection to the extent that the cost of those
drugs is covered by the other program.
    The Department of Healthcare and Family Services shall
establish by rule the methods by which it will provide for the
coverage called for in this subsection. Those methods may
include direct reimbursement to pharmacies or the payment of a
capitated amount to Medicare Part D Prescription Drug Plans.
    For a pharmacy to be reimbursed under the program
established under this subsection, it must comply with rules
adopted by the Department of Healthcare and Family Services
regarding coordination of benefits with Medicare Part D
Prescription Drug Plans. A pharmacy may not charge a
Medicare-enrolled beneficiary of the program established under
this subsection more for a covered prescription drug than the
appropriate Medicare cost-sharing less any payment from or on
behalf of the Department of Healthcare and Family Services.
    The Department of Healthcare and Family Services or the
Department on Aging, as appropriate, may adopt rules regarding
applications, counting of income, proof of Medicare status,
mandatory generic policies, and pharmacy reimbursement rates
and any other rules necessary for the cost-efficient operation
of the program established under this subsection.
    (h) A qualified individual is not entitled to duplicate
benefits in a coverage period as a result of the changes made
by this amendatory Act of the 96th General Assembly.
(Source: P.A. 96-804, eff. 1-1-10; 97-74, eff. 6-30-11; 97-333,
eff. 8-12-11.)
 
    (320 ILCS 25/4.05)
    Sec. 4.05. Application.
    (a) The Department on Aging shall establish the content,
required eligibility and identification information, use of
social security numbers, and manner of applying for benefits in
a simplified format under this Act, including claims filed for
new or renewed prescription drug benefits.
    (b) An application may be filed on paper or over the
Internet to enable persons to apply separately or for both a
property tax relief grant and pharmaceutical assistance on the
same application. An application may also enable persons to
apply for other State or federal programs that provide medical
or pharmaceutical assistance or other benefits, as determined
by the Department on Aging in conjunction with the Department
of Healthcare and Family Services.
    (c) Applications must be filed during the time period
prescribed by the Department.
(Source: P.A. 96-804, eff. 1-1-10.)
 
    (320 ILCS 25/5)  (from Ch. 67 1/2, par. 405)
    Sec. 5. Procedure.